I  i^ 


RECONSTRUCTION 
THERAPY 


BY 

WILLIAM  RUSH  DUNTON,  JR.,  M.D. 

ASSISTANT  PHYSICIAN  AT  SHEPPARD  AND  ENOCH  PRATT  HOSPITAL, 
TOWSON,  MARYLAND;  INSTRUCTOR  IN  PSYCHIATRY  AT  THE  JOHNS 
HOPKINS  UNIVERSITY;  PRESIDENT  OF  THE  NATIONAL  SOCIETY  AND 
OF  THE  MARYLAND  SOCIETY  FOR  THE  PROMOTION  OF  OCCUPATIONAL 
THERAPY;  SECRETARY  OF  THE  MARYLAND  PSYCHIATRIC  SOCIETY 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1919 


Copyright,  1919,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


FT          : 
library 

WJ3 


MEAE  CONJUGI 


577746 


CREDO 


That  occupation  is  as  necessary  to  life  as  food  and 
drink. 

That  every  human  being  should  have  both  physical 
and  mental  occupation. 

That  all  should  have  occupations  which  they  enjoy, 
or  hobbies.  These  are  the  more  necessary  when 
the  vocation  is  dull  or  distasteful.  Every  indi- 
vidual should  have  at  least  two  hobbies,  one  out- 
door and  one  indoor.  A  greater  number  will 
create  wider  interests,  a  broader  intelligence. 

That  sick  minds,  sick  bodies,  sick  souls,  may  be 
healed  thru  occupation. 


PREFACE 


IN  an  endeavor  to  sum  up  the  results  of  a  number  of 
years  experience  and  study  of  a  subject  which  is  in 
process  of  growth,  there  is  great  danger  that  what  one 
says  may  become  out  of  date.  It  is  only  since  the 
Great  War  that  Reconstruction  Therapy  has  attracted 
the  general  attention  and  interest  that  I  believe  it 
deserves.  With  this  sudden  interest  it  seems  to  me 
that  there  is  a  danger  lest  the  well-meant  enthusiasm 
of  poorly  informed  disciples  may  do  harm.  While  this 
book  was  planned  and  partly  written  before  1915  it 
has  been  necessary  to  broaden  its  scope  to  include  certain 
aspects  of  the  subject  which  have  become  more  promi- 
nent since  that  period.  The  present  time  is  one  of 
great  and  sudden  changes  which  require  rapid  physical 
and  mental  adjustments  of  the  individual.  As  a  con- 
sequence many  are  unable  to  keep  their  normal  poise 
and  suffer  mental  breakdowns.  Others  by  a  physical 
disability  and  a  fear  of  inability  to  adjust  themselves 
to  living  conditions  may  suffer  with  a  disabling  inhibition 
of  their  mental  powers.  It  has  been  proved  that  recon- 
struction therapy  can  be  used  to  restore  both  the  phys- 
ically and  mentally  sick  to  their  normal  or  perhaps 
above  it,  and  make  them  once  more  useful  units  in  a 
community.  If,  therefore,  I  have  added  anything 
which  will  be  helpful  to  those  who  are  helping  others  I 
shall  feel  that  I  have  not  labored  in  vain. 

It  is  extremely  difficult  when  one  has  received  knowl- 
edge or  stimulus  from  so  many  sources,  so  many  friends, 
to  give  proper  credit.  I  have  tried  to  indicate  in  every 
case  where  a  published  statement  has  been  of  assistance. 

11 


12  PREFACE 

This  has  been  impossible  for  the  many  thoughts  which 
have  followed  talks  with  others,  or  a  sight  of  some  object. 
I  must  therefore  run  the  risk  of  appearing  ungrateful. 

Ackowledgment  should  be  made,  however,  to  Miss 
Ada  M.  Carr,  Miss  Mary  A.  Tucker  and  Miss  Florence 
E.  Green  for  much  assistance  in  the  preparation  of  the 
manuscript. 

To  Dr.  W.  L.  Russell  and  the  Bruce  Publishing 
Company,  Judge  Quentin  D.  Corley  and  the  Johnston 
Printing  and  Publishing  Company,  Mr.  Douglas  C. 
McMurtrie  and  the  Red  Cross  Institute  for  Crippled  and 
Disabled  Men,  and  Dr.  Britton  D.  Evans  I  am  indebted 
for  the  use  of  a  number  of  blocks  used  for  the  illustrations. 

My  thanks  are  also  due  the  publishers  for  their 
cooperative  spirit. 

WILLIAM  RUSH  DUNTON,  JR. 

TOWSON,  MD., 
March,  1919. 


CONTENTS 


CHAPTER  I 

PAGE 

INTRODUCTION 17 

General  Tests : 34 

Directions  Test 34 

CHAPTER  II 

WHAT  OCCUPATION  Is 43 

CHAPTER  III 

THE  QUALIFICATIONS  OF  AN  OCCUPATION  DIRECTOR  ....  50 

CHAPTER  IV 

THE  DUTIES  OF  THE  OCCUPATION  DIRECTOR 55 

The  State  Hospital 59 

Incorporated  Hospitals 64 

Psychiatric  Clinic 66 

General  Hospital 67 

CHAPTER  V 

HELPS 69 

Sheppard  and 'Enoch  Pratt  Hospital  Handicraft  Record.  73 

CHAPTER  VI 

FINANCIAL 74 

CHAPTER  VII 

TRAINING  COURSES 78 

CHAPTER  VIII 

AMUSEMENTS 89 

Moving  Pictures 90 

Dramatics 91 

Orchestra .  92 

13 


14  CONTENTS 

PAGE 

Lectures 92 

Outdoor  Games 93 

Basket  Ball 94 

Volley  Ball  Games 94 

Field  and  Track  Athletics 95 

CHAPTER  IX 

WORKSHOPS 98 

CHAPTER  X 

OCCUPATIONAL  THERAPY  AND  THE  WAR 106 

Invalid  Occupation 114 

Occupational  Therapy  ' 117 

Vocational  Re-education 118 

Bibliography 125 

CHAPTER  XI 

PROSTHETIC  APPLIANCES 126 

CHAPTER  XII 

PHYSICAL  EDUCATION 162 

Gymnastics 175 

Occupational  Therapy 175 

Feet  Exercises 179 

CHAPTER  XIII 

OCCUPATIONS  FOR  THE  FEEBLEMINDED 182 

CHAPTER  XIV 

OCCUPATIONAL  THERAPY  FOR  THE  BLIND 187 

CHAPTER  XV 

OCCUPATIONAL  THERAPY  AND  SOCIAL  SERVICE 197 

CHAPTER  XVI 

CONCLUSION 203 

BIBLIOGRAPHY  OF  OCCUPATIONAL  THERAPY 210 

Amusements 212 

Athletics 212 

Blind 213 

Cardiac.  .  213 


CONTENTS  15 

PAGE 

Efficiency  Motion  Study 213 

Historical      214 

Hygiene 214 

Libraries 214 

Mental 215 

Neurological 220 

Outdoors  ." 221 

Rewards 221 

Training  Courses 221 

Tuberculosis 222 

Suggestive  Reference  Books 223 

AN  ABRIDGED  BIBLIOGRAPHY  OF  CRAFT  BOOKS 224 

Basketry 224 

Bookraaking 224 

Paper  Work 224 

Cord  Work 224 

Physical  Exercises 225 

Games,  etc 225 

Knitting  and  Crocheting 225 

Leather  Work 225 

Metal 225 

Needlework 225 

Plastic  Arts 226 

Typography '  . 226 

Weaving 226 

Wood  Work 226 

Drawing 226 


APPENDIX 227 

INDEX  .231 


RECONSTRUCTION  THERAPY 


CHAPTER  I 
INTRODUCTION 

It  is  a  strange  thing  that  the  physician  is  so  often  will- 
ing, even  anxious,  to  discard  remedies  which  have  proved 
efficacious  in  his  practice  and  in  that  of  others,  for  some- 
thing new  to  him  and  perhaps  hitherto  untried,  so  that 
we  have  fashions  in  therapeutics,  some  of  which  seem 
quite  as  bizarre  to  us  in  after  years  as  do  those  of  cos- 
tume. The  reason  for  changes  in  therapeutic  fashions 
is  not  due,  however,  simply  to  a  desire  for  a  change,  but 
grows  out  of  the  physician's  wish  to  do  something  more 
for  his  patient  than  he  is  already  doing,  so  that  recovery 
may  be  accelerated.  It  is  undoubtedly  true  that  ex- 
ploiters of  new  remedies  take  advantage  of  this.  With 
the  rapid  changing  of  therapeutic  fashions  it  is  not  strange 
that  at  times  we  temporarily  lose  sight  of  some  of  our 
best  remedial  measures.  On  the  other  hand,  perhaps 
these  measures  suffer  occasionally  from  too  great  en- 
thusiasm on  the  part  of  their  advocates.  The  fact  that, 
in  going  over  the  files  of  medical  journals,  we  find  certain 
drugs,  operations,  or  other  forms  of  treatment  being 
advocated  at  varying  intervals  is  probably  an  endorse- 
ment of  their  efficacy.  Were  they  valueless  no  one  would 
take  the  trouble  to  bring  them  again  to  our  knowledge. 

Two  therapeutic  measures  which  have  been  used  for 

many  years  in  caring  for  the  insane  are  water  and  work, 

and  both  of  these  have  had  periods  when  they  have  been 

warmly  advocated  and  again  when  they  have  been  barely 

2  17 


18  EECONSTRUCTION    THERAPY 

mentioned  in  medical  journals.  These  remedies,  it 
seems,  must  have  been  used  even  before  recorded  history 
and  we  know  that  Hippocrates  wrote  upon  Airs,  Waters, 
and  Places,  that  in  the  latter  part  of  the  18th  century 
hydropathy  was  fashionable,  and  that  ten  or  fifteen  years 
ago  the  use  of  prolonged  baths  and  other  forms  of  hydro- 
therapy  were  warmly  advocated  for  mental  disorders. 

The  records  of  work  therapy  are  not  so  good,  but  it  is 
easily  conceivable  that  for  ages  past  mental  cases  were 
permitted  to  occupy  themselves  in  certain  ways,  just  as 
almshouse  cases  are  permitted  to  "putter"  around  and 
do  rather  aimless  work  at  the  present  time.  No  authen- 
tic records,  however,  of  such  exist,  although  Dr.  Eva 
Charlotte  Reid  states1  that  Galen  says:  "Employment 
is  Nature's  physician."  I  have  been  unable  to  verify 
this  quotation  and  the  earliest  record  I  have  been  able 
to  find  where  work  or  occupation  has  been  advocated 
as  a  remedial  measure  is  in  Pinel's  writings  (1791). 

In  a  translation  of  Pinel,2  under  the  section  entitled 
The  Moral  Treatment  of  Insanity,  may  be  found  several 
references  to  occupation,  as  follows : 

"We  are  informed  by  Dr.  Gregory,  that  a  farmer,  in 
the  North  of  Scotland,  a  man  of  Herculean  stature, 
acquired  great  fame  in  that  district  of  the  British  em- 
pire, by  his  success  in  the  cure  of  insanity.  The  great 
secret  of  his  practice  consisted  in  giving  full  employment 

1Ergotherapy  in  the  treatment  of  mental  disorders.  Boston 
Medical  and  Surgical  Journal,  clxxi,  300,  August  20,  1914. 

2  A  Treatise  on  Insanity,  in  which  are  contained  the  principles 
of  a  new  and  more  practical  nosology  of  maniacal  disorders  than 
has  yet  been  offered  to  the  public,  exemplified  by  numerous  and 
accurate  historical  relations  of  cases  from  the  author's  public  and 
private  practice;  with  plates  illustrative  of  the  craniology  of 
maniacs  and  ideots  By  Ph.  Pinel,  Professor  of  the  School  of 
Medicine  at  Paris,  Senior  Physician  of  the  Female  National 
Asylum  la  Salpetriere,  late  Physician  in  the  Asylum  of  Becetre, 
and  member  of  many  learned  societies.  Translated  from  the 
French,  by  D.  D.  Davis,  M.  D.,  Physician  to  the  Sheffield 
General  Infirmary,  Sheffield.  Printed  by  W.  Todd,  for  Messrs. 
Cadell  and  Davies,  Strand,  London,  1806. 


INTRODUCTION  19 

to  the  remaining  faculties  of  the  lunatic.  With  that 
view,  he  compelled  all  his  patients  to  work  on  his  farm. 
He  varied  their  occupations,  divided  their  labor,  and  as- 
signed to  each,  the  post  which  he  was  best  qualified  to 
fill,  Some  were  employed  as  beasts  of  draught  or  burden, 
and  others  as  servants  of  various  orders  and  provinces. 
Fear  was  the  operative  principle  that  gave  motion 
and  harmony  to  this  rude  system.  Disobedience  and 
revolt,  whenever  they  appeared  in  any  of  its  operations 
were  instantly  and  severely  punished." 

The  same  instance  is  referred  to  by  Falret  who,  makes 
more  emphatic  condemnation:  "The  conduct  of  a  Scotch 
farmer,  mentioned  by  Gregory1  cannot  be  too  strongly 
reprehended,  who  worked  the  insane  for  the  culture  of  his 
grounds,  and  who  worked  them  like  beasts  of  burden." 
Needless  to  say  such  measures  can  hardly  be  classed  as 
occupational  therapy.  Again  (p.  72),  after  describing  a 
case  Pinel  says:  "Close  attention  to  his  trade  for  some 
months,  completed  the  restoration  of  his  intellect." 
Again  (p.  87),  "The  utmost  vigilance  of  the  domestic 
police  will  be  necessary  to  engage  the  exertions  of  every 
maniac,  especially  during  his  lucid  intervals,  in  some  em- 
ployment, laborious  or  otherwise,  calculated  to  employ 
his  thoughts  and  attention."  Again  (p.  89),  "Moderate 
employment  and  regular  exercise,  co-operating  with  the 
energies  of  nature  herself,  restored  him,  in  a  short  time, 
to  the  full  enjoyment  of  his  intellectual  faculties." 
Finally  (p.  91),  "What  I  had  done  at  Bicetre,  com- 
prehended but  a  small  part  of  my  plan  toward  ex- 
tending its  liberties  and  multiplying  its  conveniences 
for  laborious  and  other  exercises." 

The  above  translation  is  probably  that  of  PineFs 
Traite  which  was  published  in  1791,  making  Pinel  one 
of  the  earliest  advocates  of  occupation  as  a  means  of 
treatment  of  the  mentally  sick. 

The  translator,  Dr.  Davis,  in  an  introduction  to  the 
above  work,  makes  reference  to  much  earlier  therapeutic 
1  Pinel,Traite,  etc.,  p.  312, 


20  RECONSTRUCTION   THERAPY 

uses  of  occupation  and  diversion  as  follows  (p.  xxii): 
"At  both  extremities  of  ancient  Egypt,  a  country  that 
was  at  that  time  exceedingly  populous  and  flourishing, 
were  temples  dedicated  to  Saturn,  whither  melancholies 
resorted  in  great  numbers  in  quest  of  relief.  Whatever 
gifts  of  nature  or  productions  of  art  were  calculated  to 
impress  the  imagination,  were  there  united  to  the  solem- 
nities of  a  splendid  and  imposing  superstition.  The  most 
voluptuous  productions  of  the  painter  and  the  statuary 
were  exposed  to  public  view.  Groves  and  gardens  sur- 
rounded those  holy  retreats,  and  invited  the  distracted 
devotee  to  refreshing  and  salubrious  exercise.  Gaily 
decorated  boats  sometimes  transported  him  to  breathe 
amidst  rural  concerts  the  purer  breezes  of  the  Nile. 
In  short,  all  his  time  was  taken  up  by  some  pleasurable 
occupation,  or  rather  by  a  system  of  diversified  amuse- 
ments, enhanced  and  sanctioned  by  superstition."1 

Work  was  advocated  as  a  remedial  measure  in  a  letter 
written  in  1798  by  Dr.  Benjamin  Rush  to  the  Managers 
of  the  Pennsylvania  Hospital.  This  was  followed  by 
other  recommendations  that  facilities  be  given  for  oc- 
cupation, one  of  which  is  somewhat  pathetic  in  that 
reference  is  made  to  the  illness  of  a  relative  then  under 
care  in  the  hospital. 

In  1803  that  remarkable  man,  Johann  Friederich  Reil, 
published  his  Rhapsodieen  ueber  die  Anwendung  der 
psychischen  Curmethode  auf  Geisteszeruttungen,  in 
which  he  devotes  eight  pages  to  treatment  by  work,  say- 
ing (p.  240):  "Work,  moreover,  is  an  excellent  means 
besides  to  cure  insanity  itself.  It  must  be  wholesome; 
and  whenever  possible,  be  done  in  the  open  air  and  com- 
bined with  exercise  and  change."  It  is  not  possible  here 
to  quote  these  pages  in  entirety  but  they  are  of  extreme 
interest.  Reil  was  apparently  in  advance  of  his  time  in 
this  and  in  other  subjects. 

It  is  of  interest  to  note  that  in  a  decade,  in  three  coun- 

^osographie  Philosophique  par  Monsieur  le  Docteur  Pinel, 
Tome,  ii,  p.  28. 


INTRODUCTION  21 

tries,  France,  America^,  and  Germany,  strong  recommen- 
dations of  the  value  of  work  as  a  remedial  measure  in 
mental  diseases  were  written. 

In  1813  Sir  James  Connolly,  speaking  of  the  York 
Retreat,  said  "The  substitution  of  sympathy  for  gross 
unkindness,  severity,  and  stripes;  the  diversion  of  the 
mind  from  its  excitements  and  griefs  by  various  occupa- 
tions, and  a  wise  confidence  in  the  patients  when  they 
promised  to  control  themselves  led  to  the  prevalence  of 
order  and  neatness,  and  nearly  banished  furious  mania 
from  this  wisely  devised  place  of  recovery." 

A  few  years  later  (1815)  in  a  very  interesting  communi- 
cation to  the  Board  of  Governors  of  the  New  York 
Hospital,  Mr.  Thomas  Eddy,  making  recommendations 
for  the  improvement  of  the  care  of  the  insane  says: 

"8th.  Such  of'  the  patients  as  may  be  selected  by 
the  physician,  or  the  Committee  of  the  Asylum,  shall 
be  occasionally  taken  out  to  walk  or  ride  under  the  care 
of  the  deputy-keeper;  and  it  shall  be  also  his  duty  to  em- 
ploy the  patients  in  such  manner,  and  to  provide  them 
with  such  kinds  of  amusements  and  books  as  may  be 
approved  and  directed  by  the  Committee. 

"9th.  The  female  keeper  shall  endeavor  to  have 
the  female  patients  constantly  employed  at  suitable 
work;  to  provide  proper  amusements,  books,  etc.,  to 
take  them  out  to  walk  as  may  be  directed  by  the 
Committee." 

In  1822  Dr.  Wyman,  then  Superintendent  of  McLean 
Hospital,  in  his  annual  report  says  that  "the  amusements 
provided  in  the  establishment  for  lunatics,  as  draughts, 
chess,  backgammon,  nine-pins,  swinging,  sawing  wood, 
gardening,  reading,  writing,  music,  etc.,  divert  the  at-' 
tention  from  unpleasant  subjects  of  thought  and  afford 
exercise  both  of  body  and  mind  (and)  have  a  powerful 
effect  in  tranquilizing  the  mind,  breaking  up  wrong  as- 
sociations of  ideas  and  inducing  correct  habits  of  think- 
ing as  well  as  acting." 

Dr.  Bell,  who  was  later  superintendent  of  the  same  hos- 


22  RECONSTRUCTION   THERAPY 

pital,  in  his  report  for  1839  speaks  of  occupation  as  a 
means  of  cure. 

Esquirol1  praises  the  value  of  physical  exercises  and 
occupations,  and  quaintly  says  (Vol.  i,  p.  142):  "This 
valuable  resource  of  work  is  missed  in  the  treatment  of 
the  wealthier  class  of  men  and  women.  Its  place  is 
not  entirely  filled  by  supplying  walks,  music,  lectures 
and  social  events.  The  habit  of  idleness  in  the  homes 
of  the  well-to-do  counterbalances  other  advantages 
which  this  class  possess  for  recovery."  And  again  (Vol. 
ii,  p.  523)  after  speaking  of  workshops  he  says :  "If  these 
occupations  are  not  possible  for  the  wealthier  classes, 
we  must  provide  them  with  employment  fitted  to  their 
education,  giving  them  gymnastics  and  games  which 
exercise  their  muscles."  He  speaks  (ibid.)  more  directly 
when  he  says  that  work  "is  a  stimulant  to  all,"  and  that 
by  it  "we  distract  attention  from  their  illness;  we  fix 
their  attention  on  reasonable  things;  we  bring  back  to 
them  some  of  the  practices  of  order;  we  quicken  their 
intelligence;  and  in  this  way  we  improve  the  lot  of  the 
most  unfortunate." 

In  1846  Dr.  Isaac  Ray,  the  Superintendent  of  Butler 
Hospital,  wrote  a  paper  on  Labor  in  Principal  Hospitals 
for  Insane  in  Great  Britain,  France  and  Germany.  That 
same  year  Dr.  John  M.  Gait,  Superintendent  of  Eastern 
Lunatic  Asylum  of  Virginia  at  Williamsburg,  published 
a  book  entitled  "The  Treatment  of  Insanity"  in  which 
he  advises  giving  patients  employment  (p.  509).  And 
again  (p.  511)  he  amplifies  on  the  subject  as  follows: 
"No  class  of  patients  is  so  happy  as  the  laborers;  no 
other  convalescents  recover  so  rapidly  and  favorably; 
many  of  these  would  be  completely  miserable  without 
labor  and  their  recovery  retarded.  The  patient  enters 
by  it  into  accustomed  channels  of  thought  and  action, 
and  the  mind  performs  rationally  at  labor,  if  insane  every- 
where else.  .  ..  .  We  think  highly  of  employment 
to  procure  rest,  give  strength,  promote  appetite,  and 
1  Des  maladies  mentales.  Paris,  1836. 


INTRODUCTION  23 

facilitate  recovery.  When  our  patients  begin  to  mend 
they  desire  employment.  Common  amusements  of 
hospitals  are  useful,  and  far  better  than  nothing;  but 
will  not  compare  with  labor  as  a  means  of  restoration. 
It  is  true  that  "all  work  and  no  play  makes  Jack  a  dull 
boy."  It  is  no  less  true,  that  all  play  and  no  work  be- 
comes insipid  after  a  while,  and  does  not  give  that  healthy 
impulse  to  the  mind  which  the  idea  of  utility  in  labor 
is  sure  to  impart." 

In  1846  Dr.  John  Evans,  of  Illinois,  in  an  article  on  the 
treatment  of  insanity1  recommended  the  employment  of 
patients. 

In  1852  there  was  published2  an  extract  from  a  letter 
written  by  a  "manager"  stating:  "By  all  pleasant  and 
winsome  sights  and  sounds,  by  cheerful  occupation,  by 
outdoor  labor  and  indoor  sports  or  mechanical  pastimes, 
ought  "minds  diseased"  be  won  from  their  gyrations — 
their  never-ending  rotation  upon  the  point  of  fallacy." 

In  1854  the  famous  Dr.  Kirkbride  in  an  article  treat- 
ing of  the  construction,  organization  and  management 
of  hospitals  for  the  insane3  says:  "Labor  then  is  one  of 
our  best  remedies;  it  is  as  useful  in  improving  the  health 
of  the  insane,  as  in  maintaining  that  of  the  sane.  It  is 
one  of  the  best  anodynes  for  the  nervous,  it  composes  the 
restless  and  excited,  promotes  a  good  appetite  and  a  com- 
fortable digestion,  and  gives  sound  and  refreshing  sleep 
to  many  who  would  without  it  pass  wakeful  nights." 

Henri  Falret4  in  an  extremely  interesting  article  on 
the  Construction  and  Organization  of  Establishments 
for  the  Insane,  makes  a  number  of  references  to  early 
writers  on  the  subject. 

Falret  himself  says  in  speaking  of  Occupations  and 
Amusements  for  the  Insane,  '  Since  Pinel5  has  demon- 

1  American  Journal  of  Insanity,  Vol.  iii,  p.  259. 

2  American  Journal  of  Insanity,  Vol.  viii,  p.  292,  January,  1852. 

3  American  Journal  of  Insanity,  Vol.  xi,  p.  147,  October,  1854. 

4  American  Journal  of  Insanity,  Vol.  x,  p.  218,  April,  1854. 

8  Trait6  medico-philosophique  sur  1'alienation  mentale,  p.  237. 


24  RECONSTRUCTION   THERAPY 

strated  the  happy  effects  of  occupation  in  asylums, 
all  physicians  concur  in  the  opinion  that  it  is  one  of  the 
most  important  principles  in  the  treatment  of  the  in- 
sane, and  in  the  organization  of  the  establishments 
destined  for  their  reception.  Is  it  not  the  best  and  most 
effectual  way  of  regulating  their  life,  of  fixing  their  atten- 
tion, of  diverting  them,  of  giving  their  faculties  a  positive 
and  well-determined  direction,  in  one  word,  of  regulating 
their  physical  and  moral  actions?" 

Surely  these  are  wise  words  and  those  which  follow 
are  also  of  value.  He  alludes  to  the  Salpetriere  as  "one 
of  the  first  French  asylums  where  work  has  been  consid- 
ered honorable."  He  also  discusses  Occupation  for 
Women,  Theatricals,  Schools  and  Reunions.  The  fol- 
lowing quotation  from  theatricals  is  of  interest:  "In  the 
establishments  of  Charenton,  Aversa  and  Sonnenstein, 
they  have  heretofore — and  it  is  a  singular  idea — had 
theatrical  plays  by  the  insane,  and  according  to  Reil1 
and  to  Schwzeigger,2  nothing  better  attracts  the  atten- 
tion of  the  patients  or  produces  a  happier  impression,  es- 
pecially if  the  pieces  are  composed  so  as  to  throw  ridicule 
upon  their  delirious  ideas.  We  think  with  Esquirol,3 
Nostiz,4  Frank,5  Roller,6  and  Guislain,7  that  these  plays 
result  in  evil  rather  than  good,  and  it  is  better  to  re- 
nounce them  entirely." 

Dr.  W.  Lauder  Lindsay,  Superintendent  of  James 
Murray's  Royal  Asylum  at  Perth,  Scotland,  in  his  re- 
port for  1860-61,  gives  a  very  admirable  exposition  of  the 
value  of  occupation.8 

1  Rhapsodien,  p.  246. 

2Ueber  Kranken  und  armen  Anstalten  zu  Paris,  etc.,  p.  11  a  15 
et  19  a  27. 

3  Art.  Folie,  p.  228. 

4  Beschreibung,  etc.,  pp.  340,  342. 
BPraecepta,  p.  694. 

6  Die  Irrenanstalt,  p.  206. 

7  Traite"  sur  1'alienation  mentale  et  les  hospices  d'alienes,  p.  277. 

8  Reprinted  in   Maryland  Psychiatric  Quarterly, 'Vo\.  iii,  p.  10, 
July*1913. 


INTRODUCTION  25 

From  the  published  records  of  the  Pennsylvania 
Hospital,  the  Friends'  Asylum,  and  McLean  Asylum  (the 
last  two  are  now  called  hospitals)  we  know  that  these 
institutions  have  for  the  greater  part  of  their  existence 
been  active  in  providing  various  forms  of  occupation 
for  the  patients. 

The  first  number  of  the  American  Journal  of  Insanity 
was  published  in  July,  1844,  and  from  the  first  volume 
has  contained  reports  of  the  proceedings  of  the  Associa- 
tion of  Medical  Superintendents  of  American  Institu- 
tions of  the  Insane,  since  1893  the  American  Medico- 
Psychological  Association,  so  that  its  pages  give  us  a 
representative  view  of  the  opinions  of  those  in  charge  of 
the  mentally  sick.  In  going  over  the  files  of  this  journal 
we  find  many  references  to  occupation  and  many  strong 
endorsements  of  its  value  as  a  therapeutic  measure. 
Very  many  of  these  opinions  have  been  expressed  in  the 
reports  of  various  institutions  and  are  quoted  in  sum- 
maries, etc.  It  would  appear,  however,  that  during  the 
latter  part  of  the  last  century  the  majority  of  hospital 
superintendents  lost  sight  of  the  therapeutic  value  of 
occupation  and  were  too  prone  to  regard  only  its  eco- 
nomic aspect.  This  opinion  is  confirmed  by  Dr.  Frank 
Crampton  Hoyt,  Superintendent  of  Iowa  State  Hospital 
at  Clarinda,  who  in  a  paper  read  before  the  association 
in  1898  says: 

"Notwithstanding  that  for  half  a  century  the  superin- 
tendents of  our  American  hospitals  for  the  insane  have 
had  their  attention  called  repeatedly  to  the  "Occupa- 
tion treatment  of  the  insane,"  the  fact  remains  that  many, 
and  permit  me  to  say,  far  too  many,  can  report  no  greater 
diversity  of  employment,  nor  more  methodical  applica- 
tion of  this  form  of  treatment,  than  was  done  fifty  years 
ago. 

"That  this  state  of  affairs  exists  is  not  due,  as  I  have 
said  before,  to  any  serious  doubt  as  to  the  value  of  this 
method,  but  rather  to  an  imperfect  appreciation  of  its 
inestimable  value  as  a  means  of  treatment,  regardless 


26  RECONSTRUCTION    THERAPY 

of  its  economic  features.  Others  factors,  such  as  im- 
perfect appliances,  insufficient  appropriations,  the  dis- 
inclination of  patients  to  work,  the  fact  that  the  patient 
knows  that  he  cannot  be  compelled  to  work,  and,  most 
important  of  all,  the  lack  of  tact  on  the  part  of  the  med- 
ical officers  of  hospitals,  enter  into  the  arguments  of  those 
who  would  defend  their  inactivity  in  this  direction,  to- 
day, as  they  did  many  years  ago.  To  those  who  have 
given  the  subject  practical  study  none  of  these  objec- 
tions appear  unsurmountable  and  many  of  them  seem 
positively  trivial.  The  rock  upon  which  are  wrecked 
many  of  the  newly  launched  ships  of  industrial  treat- 
ment is  that  of  Economy.  "  Does  it  pay?"  is  the  question 
most  frequently  asked  by  the  visitors  to  our  industrial 
department,  and  it  is  this  question  of  profit  and  loss  which 
is  so  prominent  a  feature  in  many  discussions  of  this 
subject.  As  well  might  one  ask  does  it  pay  to  administer 
drugs,  use  the  knife,  provide  skilled  nurses  and  the  various 
paraphernalia  of  a  well-organized  hospital.  Industrial 
treatment  of  the  insane  does  pay.  When  properly  ap- 
plied it  pays  enormous  profits,  profits  which  though 
they  may  not  be  visible  on  the  credit  side  of  the  ledger, 
are  yet  in  evidence  in  the  wards  of  the  hospital.  The 
profit  is  to  be  readily  found  in  the  absence  of  large  num- 
bers of  half  or  wholly  demented  patients  lined  up  along 
the  wall  of  the  wards;  in  the  healthy,  cheerful  faces  of 
the  patients  in  the  quiet  wards,  the  freedom  from  vio- 
lence, destruction  and  vicious  habits,  so  common  in 
many  hospitals."1 

The  reports  of  hospitals  and  the  reminiscences  of  men 
who  were  in  charge  of  hospitals  also  serve  to  confirm 
this  view.  Possibly  hospital  physicians  had  the  opinion 
which  was  expressed  to  me  in  1903  by  the  superintendent 
of  a  large  state  hospital  who  when  asked  if  he  employed 
his  patients,  almost  indignantly  replied  that  he  did 

1  Occupation  in  the  treatment  of  the  insane.  Transactions  of 
the  American  Medico-Psychological  Association,  Vol.  v,  1898, 
p.  288. 


INTRODUCTION  27 

not  believe  in  working  sick  people.  He  apparently  did 
not  realize  that  in  condemning  his  patients  to  idleness 
he  was  doing  them  a  great  harm. 

It  seems  probable,  however,  that  the  Civil  War  brought 
about  more  engrossing  problems  than  medical  care  and 
that  in  many  instances  this  was  necessarily  slighted. 
For  many  years  there  have  been  hospitals  where  work 
has  been  used  intelligently,  and  we  find  leaders  of  pys- 
chiatry  advocating  the  use  of  work  as  a  remedial  measure. 
This  is  proved  by  the  preceding  quotations. 

During  the  past  ten  years  there  has  been  a  renascence 
of  interest  in  the  subject  of  work  therapy.  This  was 
largely  due  to  Miss  Susan  E.  Tracy,  whose  book  on 
Invalid  Occupations  was  published  in  1910.  Following 
its  publication  it  was  quickly  realized  that  occupation 
is  one  of  the  best  of  the  means  we  have  for  aiding  the 
recovery  of  the  sick. 

In  psychiatry  it  has  been  recognized  for  a  long  time 
that  the  mental  effort  required  to  perform  some  task, 
or  make  some  object,  has  had  a  beneficial  effect  in  co-or- 
dinating the  mental  functions,  so  that  we  often  hear  oc- 
cupation spoken  of  as  re-education.  In  more  recent  times 
in  other  specialties  than  psychiatry,  re-educational 
efforts  have  been  utilized  for  the  restoration  of  impaired 
function.  I  am  not  so  familiar  with  the  literature  of 
other  specialties  as  with  that  of  psychiatry,  so  cannot 
give  such  an  accurate  account  of  the  development  of 
occupation  or  re-education  in  these  branches  of  medicine, 
but  it  is  common  knowledge  that  for  nearly  a  century 
the  blind  have  been  educated  to  substitute  other  senses 
for  the  absent  sight.  Some  of  the  things  done  by  the 
well-trained  blind  appear  almost  uncanny  to  the  seeing. 
Some  years  ago  I  made  an  inquiry1  of  the  emotional  re- 
action of  those  to  whom  blindness  came  in  adult  life  and 
incidentally  found  many  examples  of  how  regular,  pur- 


1  Mental  State  of  the  Blind.     American  Journal  of  Insanity, 
Vol.  Ixv,  p.  103,  July,  1908. 


28  RECONSTRUCTION   THERAPY 

poseful  occupation  can  improve  the  mental  condition 
of  such  patients. 

It  is  also  quite  well  known  that  for  many  years  neu- 
rologists have  sought  to  re-establish  function  in  paralyzed 
or  partially  paralyzed  limbs  by  the  use  of  re-educational 
exercises.  A  great  deal  of  benefit  frequently  follows 
these  measures.  More  recently  Dr.  William  J.  M.  A. 
Maloney1  and  Dr.  Shepherd  Ivory  Franz2  have  empha- 
sized the  psychic  factor  in  this  form  of  re-education. 

During  the  present  Great  War  very  active  measures 
have  been  undertaken  for  the  re-education  of  the  crippled 
soldiers  in  order  that  they  may  be  restored  to  at  least 
partial  activity  and  self-support.  Many  ingenious 

1  Maloney,  William  J.  M.  A.     Blindness  and  Tabes.     Journal 
of  Nervous  and  Mental  Diseases,  Vol.  xl,  No.  9  (1913). 

Fear  and  Ataxia.     Ibid.,  Vol.  xl,  No.  11  (1913). 

The  Cure  of  Ataxia.  New  York  Medical  Journal,  Vol.  xcviii,  p. 
1045,  November  29,  1913. 

The  Mechanism  of  Mental  Processes  as  Revealed  in  Reckoning. 
Journal  of  Psychology,  about  Marchr  1914. 

Determinants  of  Tabes.  New  York  Medical  Journal,  Vol.  xcix, 
p.  1225,  June  20,  1914. 

Maloney  and  Sorapure.  Relief  of  States  of  Vascular,  Muscular 
and  Mental  Tension.  New  York  Medical  Journal,  Vol.  xcix,  p. 
1021,  May  23,  1914. 

Ibid.  Note  on  Mechanical  Support  of  the  Feet  in  Locomotor 
Ataxia.  Medical  Record,  Vol.  xcix,  May,  1914. 

Other  papers  in  Journal  of  Nervous  and  Mental  Disease  on 
apparatus  for  recording  and  curing  motor  disturbances  of  head 
and  of  respiration.  Grossman  has  written  on  the  use  of  the 
method  in  tics  and  chorea.  Pollen  and  Abrahamson  on  its 
application  to  functional  motor  disorders,  and  Wolf  on  its  use  in 
ataxia. 

2  The  Possibility  of  Recovery  of  Motor  Function  in  Long-stand- 
ing Hemiplegia.     A  Preliminary  Report.     Journal  of  the  American 
Medical  Association,  Vol.  Ixv,  pp.  2150-2155,  December  18,  1915. 

The  Effects  of  Cerebral  Destruction  upon  Habit-formation  and 
Retention  in  the  Albino  Rat.  Psychobiology,  Vol.  i,  pp.  71-134, 
September,  1917. 

The  Retention  of  Habits  by  the  Rat  after  Destruction  of  the 
Frontal  Portion  of  the  Cerebrum.  Psychobiology,  Vol.  i,  pp.  3-18, 
July,  1917. 


INTRODUCTION  29 

appliances  have  been  devised  and  a  tremendous  impetus 
has  been  given  to  this  form  of  re-education  or  occupation. 

Occupational  therapy  has  also  been  applied  to  the 
tuberculous1  and  to  cardiacs.2  In  both  of  these  groups 
it  has  been  found  that  by  carefully  graded  exercises  the 
patients  may  be  assisted  materially  in  gaining  their 
physical  health  and  become  to  a  greater  or  less  degree 
economic  assets  rather  than  liabilities. 

As  may  be  inferred  from  the  foregoing  it  is  a  very 
simple  matter  to  trace  the  development  of  occupational 
therapy  from  simple  tasks  and  amusements  to  the  more 
scientific  occupational  therapy  or  re-education  which  is 
applied  to  practically  all  forms  of  mental  and  physical 
disability.  There  still  remains  much  to  be  done,  however, 

1  Barton,   George  Edward.     Occupation  and  Auto-inoculation 
in   Tuberculosis.     The   Trained  Nurse  and  Hospital  Review,  Sep- 
tember and  October,  1916. 

Brown,  Philip  King,  M.  D.  The  Potteries  of  Arequipa  Sani- 
tarium. The  Modern  Hospital,  Vol.  viii,  June,  1917. 

Dumarest,  Dr.  F.  et  Dr.  A.  Vigne.  Organization  et  mise  en 
oeuvre  d'un  cure  de  travail  dans  un  sanitarium  populaire.  Paris 
medicale,  1916,  Vol.  vi,  No.  30.  Abstracted  in  Modern  Hospital, 
Vol.  ix,  p.  142,  August,  1917. 

Famenne.  Le  travail  manuel  agent  de  therapeutic  physique. 
Journal  de  Physiotherapie,  Paris,  1910,  Vol.  viii,  pp.  551-558. 

Farrand,  Dr.  Livingston.  Occupation  in  Relation  to  Tuber- 
culosis. Proceedings  of  Sixteenth  Annual  Convention  of  Ameri- 
can Society  of  Superintendents  of  Training  Schools  for  Nurses, 
1910,  p.  201. 

Ford,  James  S.,  M.  D.  The  Employment  of  Persons  in  the 
Arrested  Stage  of  Tuberculosis.  Medical  Record,  Vol.  xc,  p.  1154, 
December  30,  1916. 

Patterson,  Marcus.  Auto-inoculation  in  Pulmonary  Tuber- 
culosis. London,  James  Nisbet  &  Co. 

Stein,  Fred  M.  Family  Care  of  the  Tuberculous.  Journal  of 
the  Outdoor  Life,  Vol.  xiv,  p.  135,  May,  1917. 

Hochhauser,  Edward.  Home  Treatment  for  the  Tuberculous. 
The  Modern  Hospital,  Vol.  viii,  p.  207,  March,  1917. 

Report  of  the  New  York  Committee  on  the  Care  of  the  Jewish 
Tuberculous,  1916. 

2  First  Annual  Report  of  the  Trade  School  for  Cardiac  Con- 
valescents, July,  1913- July,  1914. 

Second  report  of  same,  July,  1914- January,  1916. 


30  RECONSTRUCTION   THERAPY 

before  ergotherapy  can  be  considered  as  an  exact  science. 
Fortunately,  there  is  a  much  wider  interest  in  the  subject 
and  many  persons  are  studying  it.  As  can  easily  be 
imagined,  there  are  many  difficulties,  but  psychologic 
methods  are  gradually  conquering  them.  A  decided 
step  was  made  by  Miss  Helen  Grace  Kent  in  her  paper 
entitled  "Experiments  in  Habit  Formation  in  Dementia 
Praecox," l  but  as  yet  only  Boring  has  had  the  patience  to 
make  a  similar  investigation  of  any  of  the  crafts.  Besides 
measuring  the  attention  by  means  of  the  reaction  time  it  is 
necessary  to  have  some  sort  of  gauge  for  the  emotions,  and 
so  far  no  such  standard  has  been  formulated.  Fatigue 
also  enters  into  the  problem  and  while  considerable  study 
has  been  done  upon  this  subject,  there  is  yet  much  to  be 
learned.  The  work  of  Mosso2  is  probably  the  best  for 
our  purpose  but  there  are  many  others,  among  them 
Fatigue  Studies3  by  Mr.  and  Mrs.  F.  B.  Gilbreth. 

The  subjects  of  Miss  Kent's  investigation  were  women 
patients  at  the  Government  Hospital  at  Washington, 
who  at  the  first  interview  gave  promise  of  co-operation. 
The  experiments  were  (a)  the  arrangement  of  digits 

1  The  Psychological  Review,  Vol.  xviii,  p.  374,  November,  1911. 

2  New  York,  1916,  Sturgis  and  Walton. 

3  Fatigue.     Translated   by  Margaret  and  W.  B.  Drummond. 
New  York,  1906,  G.  P.  Putnam's  Sons. 

See  also  The  Mental  Symptoms  of  Fatigue,  by'Edward  Cowles, 
M.  D.  Transactions  of  the  New  York  State  Medical  Association, 
November  16,  1892. 

Normal  Performance  in  the  Tapping  Test  Before  and  During 
Practice,  with  Special  Reference  to  Fatigue  Phenomena,  by  F.  L. 
Wells.  American  Journal  of  Psychology,  Vol.  xix,  pp.  437-438, 
October,  1908. 

A  Neglected  Measure  of  Fatigue,  by  F.  L.  Wells.  American 
Journal  of  Psychology,  Vol.  xix,  pp.  345-358,  July,  1908. 

Mental  Fatigue,  by  E.  L.  Thorndike.  Journal  of  Educational 
Psychology,  Vol.  ii,  pp.  61-80. 

Mental  Fatigue  in  Day-school  Children,  as  Measured  by 
Arithmetical  Reasoning.  British  Journal  of  Psychology,  Vol.  iv, 
pp.  315-341,  1911. 

The  Nature  of  Fatigue,  by  F.  S.  Lee.  Popular  Science  Monthly, 
Vol.  Ixxvi,  pp.  182-195,  1910. 


INTRODUCTION  31 

mounted  on  cardboard  squares  according  to  a  fixed 
scheme,  (6)  a  maze  puzzle,  (c)  marking  similar  figures, 
(d)  placing  twenty  pegs  in  holes,  and  (e)  re-arrangement 
of  ten  blocks.  The  results  are  carefully  analyzed  and 
the  following  conclusions  are  given : 

''Definite  practice  effects  can  be  obtained,  by  means  of  a 
short  series  of  tests,  from  advanced  cases  of  dementia 
praecox. 

"The  willingness  of  the  subject  to  co-operate  consti- 
tutes an  important  variable.  The  means  employed  for 
obtaining  the  co-operation  of  insane  subjects  must  be 
adapted,  to  some  extent,  to  the  individual. 

"The  importance  of  giving  a  patient  special  training  as 
to  the  proper  method  of  performing  a  given  task  is  clearly 
indicated  by  the  failure  of  these  subjects  to  devise 
economical  methods. 

"Practice  effect  gained  in  one  kind  of  work  appears  to 
be  to  some  extent  transferable  to  another  kind  of  work 
which  differs  from  the  first  in  its  perceptual,  but  not 
in  its  motor  aspects. 

"In  any  attempt  to  establish  a  new  habit  in  a  patient, 
it  is  well  to  take  advantage,  as  far  as  possible,  of  habits 
already  present. 

"There  are  indications  that  some  of  the  energy  ordi- 
narily expended  in  mischievous  performances  may, 
by  careful  training,  be  directed  into  more  favorable 
channels  (subject  14).  These  findings  offer  some  promise 
that  results  of  practical  value,  both  economic  and  thera- 
peutic, may  be  obtained  by  an  extension  of  this 
investigation." 

Following  is  a  part  of  the  general  considerations: 

"During  the  first  two  weeks  of  the  experiments  with 
the  first  group  of  subjects,  several  of  them  were  regularly 
brought  from  another  ward  to  the  ward  in  which  the 
tests  were  conducted,  and  while  waiting  for  their 
turn  they  occupied  a  seat  in  the  corridor,  just  outside 
the  door  of  the  experimenting  room.  Later  these  patients 
were  transferred  to  this  ward,  and  for  several  days  they 


32  RECONSTRUCTION   THERAPY 

could  with  difficulty  be  induced  to  leave  that  seat; 
even  subject  1,  who  was  considerably  disturbed  by 
the  change,  remained  in  that  part  of  the  corridor  for 
some  days,  and  was  regularly  found  there  waiting  for 
her  turn. 

"Several  subjects  showed  a  tendency  to  resent  the  most 
trifling  deviations  from  the  routine  of  the  test  period, 
such  as  a  change  in  the  order  in  which  different  tests 
were  presented.  Subject  4  was  greatly  displeased  when 
she  was  called  away  from  her  daily  work  of  scrubbing  the 
floor.  Subject  2  was  considerably  disconcerted  by  the 
request  to  perform  the  tasks  in  an  unaccustomed  place. 
On  one  occasion,  subject  9  was  called  to  the  experimenting 
room  ahead  of  the  patient  who  had  preceded  her  at 
the  last  few  interviews;  she  protested  that  it  was  not 
her  turn,  and  when  asked  what  difference  it  made 
replied  that  everything  should  be  done  in  order.  Another 
time  she  said,  "I  can't  take  my  lesson  today,  because 
I  didn't  have  my  bath  this  morning;  the  bath  has  to 
come  first."  She  was  with  difficulty  persuaded  to  per- 
form the  tasks,  and  gave  a  very  poor  record.  Both 
this  patient  and  also  subject  3  were  displeased  when 
the  experiments  were  discontinued.''' 

It  should  be  noted  that  nowhere  does  Miss  Kent 
make  any  special  comment  on  the  value  of  enlisting 
the  patient's  interest,  which  those  who  practise  occupa- 
tional therapy  recognize  as  a  most  important  factor. 
The  word  occurs  but  seldom,  as  follows:  "The  tasks 
which  were  assigned  to  them  possessed  little  or  no  in- 
trinsic interest."  "Subject  1  ...  After  a  week  or 
two  the  patient  adapted  herself  to  the  ward,  but  her 
interest  in  the  experiments  was  lost,  and  throughout  the 
series  her  co-operation  was  variable.  At  the  time  when 
experiment  C  was  commenced  she  was  in  a  favorable 
mood  and  showed  much  interest  in  the  preliminary 
tests."  "Subject  11  ...  At  first  gave  very  good 
co-operation,  evidently  hoping  that  the  results  would 
prove  her  to  be  in  good  mental  health.  Gradually,  as  she 


INTRODUCTION  33 

began  to  realize  that  this  was  not  the  purpose  of  the 
experiment,  she  lost  her  interest  in  it."  " Subject 
14  ...  She  apparently  lacked  either  the  intelli- 
gence or  the  interest  to  undertake  tasks  which  called  for 
voluntary  attention." 

It  is  easily  conceivable  that  tests  more  stimulating  to 
the  patient's  interest  might  have  been  used,  and,  in  fact, 
Miss  Kent  did  make  slight  use  of  a  puzzle  picture  and 
of  hemming,  but  it  is  to  be  regretted  that  the  study  was 
not  carried  on  further  with  these  or  other  interesting 
occupations.  Even  so,  it  is  a  most  valuable  one. 

During  the  summer  of  1912,  Mr.  Edwin  G. Boring,  Assist- 
ant in  Psychology  at  Cornell  University,  made  a  study 
somewhat  similar  to  Miss  Kent's,  upon  eight  subjects  at 
the  Government  Hospital. l  All  of  these  patients,  with  the 
probable  exception  of  one,  were  cases  of  dementia  prsecox. 
Mr.  Boring,  with  the  advantage  of  Miss  Kent's  pioneer 
work,  made  a  more  complete  study  of  habit  formation.  A 
radical  difference  in  the  interpretation  of  data  was  due  to 
the  "  availiablity  of  additional  information  furnished  by 
the  introspections"  which  the  subjects  were  trained  to  give. 
It  is  notable  in  this  report  that  much  more  attention 
is  paid  to  the  interest  shown  by  the  subject,  and  the  final 
test  of  rug  making  was  changed  in  order  to  add  interest. 
"The  experimental  rugs  were  made  32  by  18  inches. 
It  was  planned  to  make  them  perfectly  plain  without  any 
pattern  at  all,  in  order  that  they  might  be  equally 
difficult  throughout.  After  commencing  work,  however, 
it  was  discovered  that  the  work  was  so  monotonous  that 
the  subjects  before  long  grew  tired  of  it,  and  it  soon  be- 
came a  question  whether  they  could  be  kept  at  it  long 
enough  to  finish  the  rugs.  Accordingly,  a  pattern  was 
introduced  in  order  to  stimulate  interest  and,  later  the  pat- 
tern was  complicated  somewhat  for  the  same  purpose." 

There  was  a  preliminary  training  period  of  two  weeks, 
during  which  the  subjects  were  given  the  following  tests: 

1  Learning    in    Dementia    Praecox,    Psychological    Monograph, 
No.  63. 
3 


34  RECONSTRUCTION   THERAPY 

1.  GENERAL  TESTS 

(A)  Attention  with  Simple  Stimuli. — A  series  of  150  digits 
was  read  at  the  rate  of  two  per  second  to  the  subject, 
who  was  instructed  to  tap  on  the  table  whenever  the 
digit  3  occurred,  which  it  did  25  times.     This  test  is 
outlined  by  Franz.1 

(B)  Memory  Span. — The    immediate    memory  span 
for  a  series  of   digits  was  tested  with  both  auditory 
and    visual    stimuli.     For    the    auditory    presentation 
the  numbers  were  read  to  the  subject  at  the  rate  of  two 
per  second;  for  the  visual  presentation  black  gummed 
letters  on  a  light  gray  cardboard  slide  were  presented 
one  after  the  other  through  a  window  in  a  cardboard 
slide  holder  at  the  rate  of  two  per  second.     The  subject 
was  in  each  case,  first  presented  with  two  series  of  three 
digits  each,  then  two  series  of  four  digits  each  and  so 
on  up  to  ten  digits.     The  memory  span  was  taken  as 
the  greatest  number  of  digits  correctly  repeated,  although 
the  first  mistake  may  have  occurred  for  a  smaller  number. 

(C)  Apperception  Tests. — The   Heilbronner   test  was 
used  in  which  the  subject  is  presented  with  a  series  of 
cards  with  drawings  upon  them.     The  first  card  has  in 
bare  outline  the  principal  parts  of  an  object,  the  next 
is  slightly  more  complete,  the  next  more  so,  and  so  on  to 
the  last  card,  which  bears  the  object  completed  with 
enough  detail  ordinarily  to  insure  recognition.     Series 
were  used  with  pictures  of  the  following  objects:  bicycle, 
fire-place,  fountain-pen,  lamp,  phonograph,  telephone, 
watch  and  wind-mill.     The  subject  was  asked  to  state 
what  he  thought  each  picture  represented  or,  if  he  could 
not  do  that,  to  describe  what  he  saw. 

2.  DIRECTIONS  TEST 

In  order  to  obtain  some  insight  into  the  ability  of 
the  subjects  to  understand  and  to  act  upon  the  simple 
instructions,  they  were  given  the  standard  "directions 

1  Handbook  of  Mental  Examination  Methods.  Nervous  and 
Mental  Disease  Monograph  Series  No.  10,  1912,  p.  71. 


INTRODUCTION  35 

tests"  prepared  by  Woodward  and  Wells.1  There 
are  two  of  these,  the  easy  and  the  hard,  for  the  first 
of  which  two  blanks  are  provided  of  approximately 
equal  difficulty.  These  directions  and  similar  ones  are 
given:  Write  any  word  of  three  letters,  how  many  t's 
are  there  in  twist,  write  s  in  the  middle  square  (three 
being  shown),  write  any  number  smaller  than  10,  write 
here  .  .  .  the  middle  letter  of  get.  In  the  hard  direc- 
tions test  the  object  is  to  complicate  the  directions 
somewhat,  by  calling  for  conditional  and  alternative 
responses.  These  directions  begin  as  follows:  With 
your  pencil  make  a  dot  over  any  one  of  these  letters 
F  G  H  I  J,  and  a  comma  after  the  longest  of  these 
three  words:  BOY  MOTHER  GIRL.  Then  if  Christ- 
mas comes  in  March,  make  a  cross  right  here  .  .  . 
but  if  not,  pass  along  to  the  next  question,  and  tell 
where  the  sun  rises  ...  If  you  believe  that  Edison 
discovered  America,  cross  out  what  you  just  wrote,  but 
if  it  was  some  one  else,  put  in  a  number  to  complete 
this  sentence:  "A  horse  has  .  .  .  feet." 

Both  the  easy  and  the  hard  tests  were  given,  the  two 
halves  of  the  easy  test  being  given  on  different  days. 
All  the  subjects  could  read  and  write,  although  some 
hesitated  slightly  and  tended  to  misread  when  they  did 
not  understand  the  question. 

After  these  preliminary  tests  two  tests  of  motor  control 
were  given.  The  tapping  test,  designed  to  measure  the 
greatest  speed  at  which  a  simple  muscular  movement 
can  be  performed.  The  subject  making  pencil  dots  for 
30  seconds.  The  aiming  test  was  given  to  measure  the 
accuracy  of  a  simple  muscular  movement  and  to  deter- 
mine its  dependence  upon  the  speed  of  the  movement. 

Then  followed  three  tests  of  learning,  a  kinesthetic 
memory  test,  cancellation  tests,  and  maze  tests.  The 
latter  were  somewhat  different  from  those  used  by  Miss 
Kent.  The  size  used  is  not  given  in  either  of  these 
studies. 

1  Psychological  Monograph,  57,  1911. 


36  RECONSTRUCTION    THERAPY 

The  final  tests  were  with  learning  to  make  hooked  rugs. 
At  first  the  subjects  worked  alone  but  were  later  allowed 
to  work  together  in  a  large  room.  Two  and  a  half 
hours  each  afternoon  were  given  over  to  the  work.  Ap- 
parently no  note  is  made  of  a  diminution  in  output  dur- 
ing the  latter  part  of  this  period,  but  I  believe  that  it 
was  too  long  for  such  monotonous  work. 

This  study  is  a  most  valuable  and  interesting  one 
and  I  regret  that  space  does  not  permit  a  fuller  abstract. 
The  conclusions  given  are  as  follows: 

"1.  Dementia  prsecox  patients,  can  be  readily  trained 
in  the  performance  of  simple  tests  of  learning  or  of  more 
complex  operations  of  an  industrial  nature. 

"2,  These  patients  are  available  as  subjects  for  psy- 
chological investigation,  provided  the  apparatus  used 
is  not  too  complicated.  They  can  be  trained  without 
great  difficulty  to  give  introspective  reports  of  the  more 
prominent  features  of  conscious  experience. 

"3.  The  patients  show  large  individual  differences 
in  ability  to  learn  the  operations,  in  manner  of  pro- 
cedure, and  in  the  consciousness  accompanying  the 
performance. 

"4.  The  patients  are  capable  of  fairly  precise  motor 
adjustments.  The  accuracy  of  a  very  simple  motor 
adjustment  does  not  increase  with  practice,  but  does 
depend  upon  the  extent  and  the  speed  of  movement. 
In  the  latter  case  accuracy  decreases  more  rapidly  than 
speed  increases. 

"5.  There  is  but  little  evidence  for  transfer  of  practice 
from  an  operation  that  is  but  slightly  motor  in  character. 

"6.  The  course  of  consciousness  in  learning  a  maze  s 
that  of  the  normal  subject.  Verbal,  visual;  and  attitu- 
dinal  factors  are  usually  replaced  by  kinesthetic,  which 
in  turn  lapse  as  the  movement  becomes  automatic. 

"7.  There  is  indication  that  employment  may  be  bene- 
ficial to  some  patients,  although  this  cannot  be  asserted 
positively. 

"8.  The  patients  are  capable,   in   simple  industrial 


INTRODUCTION  37 

operations  of  a  quality  of  work,  sufficiently  good  to  be 
commercially  valuable." 

For  a  number  of  years  Professor  Harry  L.  Hollings- 
worth,  of  Columbia  University,  has  been  making  ex- 
perimental and  comparative  studies  of  the  various 
methods  now  used  in  selecting  a  vocation.1  One  would 
expect  to  find  much  aid  from  work  of  this  sort  in  apply- 
ing occupational  therapy  to  our  patients.  Unfortunately 
we  do  not.  Let  me  make  a  few  quotations,  (p.  269) 
"The  evidence  now  at  hand  suggests  that  the  incomplete 
correlation  comes,  in  part  at  least,  from  the  fact  that 
some  of  the  tests  of  momentary  achievement  do  not  fully 
represent  the  ultimate  capacities  of  the  individuals 
measured."  If  this  is  true  of  so-called  normal 
individuals,  the  same  error  will  be  greatly  increased 
when  we  are  dealing  with  those  sick  in  mind  or  body, 
hence  such  methods  will  have  a  proportionately  lower 
value,  (p.  272)  "But  there  is  probably  another  factor 
in  part  responsible  for  the  incompleteness  of  the  cor- 
relation between  test  records  and  direct  measures 
of  vocational  success.  This  is  the  fact  that  char- 
acteristics other  than  general  intelligence  play  a  con- 
spicuous part  in  daily  life.  The  interests,  the 
incentives,  the  emotions,  and  the  equipment  of  instinct 
and  habit,  which  show  themselves  in  such  traits  as 
curiosity,  competition,  honesty,  loyalty,  promptness, 
patience,  the  play  impulse,  etc.,  do  not  count  for 
nothing  in  vocational  activity."  (In  my  opinion, 
they  count  for  a  great  deal,  especially  interest,  which  I 
consider  is  largely  if  not  entirely,  controlled  by  the 
emotions,  the  incentive,  and  habit.)  "Moreover,  it 
is  quite  likely  that,  in  addition  to  the  common  fund  of 
intelligence,  each  individual  possesses  in  his  or  her  own 
degree,  certain  more  specialized  capacities  and  aptitudes, 
for  the  complete  measurement  of  which  the  available  tests 
are  inadequate.  The  graded  "product  scales,"  however, 

1  Vocational  Psychology.     Its  Problems  and   Methods.     New 
York,  D.  Appleton  &  Co. 


38  RECONSTRUCTION   THERAPY 

represent  a  definite  step  toward  the  measurement  of 
many  of  these  specific  capacities."  "The  diagnosis 
of  the  instinctive  and  attitudinal  characteristics  and  the 
recognition  of  the  more  specialized  aptitudes  constitute 
two  points  at  which  the  line  of  advance  is  relatively 
slow."  v 

"The  very  fact  that  a  systematic  presentation  of  the 
problems  and  methods  of  vocational  psychology  is 
possible  signifies  an  enormous  advance  beyond  the 
very  recent  stage  in  which  all  vocations  were  mysteries, 
all  choices  a  serious  form  of  gambling,  and  all  employ- 
ment confessedly  a  matter  of  impressionistic  prejudice. 
To  those  who  become  familiar  not  only  with  the  program 
of  this  new  branch  of  applied  science,  but  as  well  with 
the  outstanding  definite  and  positive  contributions 
which  that  program  has  already  yielded,  the  words  of  a 
constructive  pioneer  in  this  branch  of  scientific  inquiry 
seem  to  be  already  becoming  a  statement  of  fact,  rather 
than  the  mere  expression  of  a  hope.  'The  nineteenth 
century  witnessed  an  extraordinary  increase  in  our 
knowledge  of  the  material  world,  and  in  our  power  to 
make  it  subservient  to  our  ends;  the  twentieth  century 
will  probably  witness  a  corresponding  increase  in  our 
knowledge  of  human  nature,  and  in  our  power  to  use  it 
for  welfare.' ' 

It  may  be  gathered  from  the  above  that  Professor 
Hollingsworth  has  given  us  a  very  suggestive  book, 
though  perhaps  not  so  helpful  as  might  be  desired. 

With  the  recognition  of  the  value  of  occupation 
therapy  a  demand  has  arisen  for  persons  qualified  to 
direct  such  treatment.  While  a  number  of  training 
schools  for  nurses,  connected  with  both  general  and  mental 
hospitals  include  a  course  of  occupation  in  the  curriculum, 
as  a  rule  it  is  not  possible  to  make  this  course  sufficiently 
complete  to  enable  the  pupils  taking  it  to  acquire  suf- 
ficient knowledge  of  the  subject  to  qualify  for  the 
position  of  director  of  occupations  or  of  industries. 
Then  too,  it  is  easily  conceivable  that  those  in  charge  of 


INTRODUCTION  39 

hospitals  might  hesitate  to  appoint  to  such  a  responsible 
position  a  person  as  young  as  are  most  of  the  recent 
graduates  of  training  schools,  so  that  in  the  past  the 
preference  has  been  to  appoint  one  of  the  senior  physicians 
to  direct  the  occupations  and  industries.  As  a  rule, 
experience  has  taught  the  physician  much  of  value. 

This  book  has  been  written  to  aid  aspirants  and  also 
with  the  hope  that  the  principles  here  laid  down  will 
be  of  benefit  and  be  an  aid  to  those  who  may  be  suddenly 
called  upon  to  assume  the  duties  of  occupation  director, 
and  that  the  results  of  the  experience  of  others  detailed 
here  may  be  helpful. 

We  will  assume  that  an  assistant  physician  has  been 
told  by  his  superintendent  that  he  is  to  take  charge  of 
the  occupation  therapy.  He  naturally  asks  what  this 
means,  of  what  does  this  consist,  and  what  are  to  be  his 
duties.  We  will  also  assume  that  the  hospital  is  a 
large  one,  with  a  number  of  so-called  industries,  and  a 
training  school.  The  duties  of  the  various  officers 
might  be  charted  as  follows: 


Board  of  Managers 

Medical  Service                            Superintendent               Administrative  Service 

erin 

tendent           Assistant  Physicians  —           ^  Director  of  >\ 

Steward 

Nurses—                                                             -"Occupation^ 

Nurses—                                                                Craft   Teachers  \ 
Athletic  Director 
Amusement  Director 
Librarian 

\   Engineer 
v  Housekeeper 
\  Laundryman 
Farmer 

Printer 

Etc. 

Shoemaker 

Weaver 

Etc. 

From  this  it  will  be  learned  that  the  Director  of  Occupa- 
tion is  responsible  to  the  Superintendent  for  the  conduct 
of  this  department.  That  the  various  Craft  Teachers, 
those  in  charge  of  the  various  industries,  the  Athletic 
Director,  the  Amusement  Director,  and  the  Librarian 
are  all  responsible  to  the  Director  of  Occupation  for  the 
conduct  of  their  departments.  That  the  Director  of 


40  RECONSTRUCTION    THERAPY 

Occupation  is  in  close  accord  with  the  Superintendent 
of  Nurses  and  those  under  her,  and  with  the  Laundry- 
man  and  the  Farmer.  The  work  of  these  last  two  is 
not  usually  carried  on  as  a  means  of  occupation  and  when 
used  as  such  can  only  be  expected  to  be  utilized  for  the 
willing  workers.  The  farmer  and  the  laundryman  can- 
not take  the  time  to  persuade  the  unwilling  or  show  the 
stupid  what  is  desired  of  them.  On  the  other  hand  the 
crafts,  industries,  and  amusements  are  conducted  solely 
as  means  of  occupation.  The  Superintendent  of  Nurses 
must  be  in  close  accord  with  the  Director  in  order  that 
her  pupils  may  be  taught  the  most  necessary  principles 
in  caring  for  patients,  and. the  nurses  must  feel  free  to 
consult  with  the  Director  as  to  the  means  of  carrying 
out  these  principles  in  individual  cases. 

Later  we  will  discuss  in  detail  some  of  these  relation- 
ships. It  is  very  necessary  that  there  be  a  complete 
understanding  between  the  heads  of  departments  having 
reciprocal  relationships  in  order  that  petty  jealousies 
and  clashes  may  be  avoided.  This  necessity,  of  course, 
is  not  limited  to  occupation  if  our  institutions  are  to 
serve  best  the  function  for  which  they  have  been  created, 
but  occupation  necessarily  calls  for  the  co-operation 
of  more  departments  than  does  some  others.  It  is  be- 
lieved that  the  use  of  charts  similar  to  that  shown  will 
do  much  to  clear  away  any  misunderstandings  and  so 
avoid  friction.  If  every  worker  would  take  to  heart 
Ali  Baba's  saying:  "People  who  never  do  any  more 
than  they  get  paid  for,  never  get  paid  for  any  more 
than  they  do,"  there  would  be  a  more  altruistic  spirit 
in  this  world,  no  labor  troubles,  and  human  efficiency 
would  increase  several  hundred  percent.  It  is  the 
shirker  who  clogs  the  wheels  of  progress.  When 
we  read  the  lives  of  successful  people  we  know  that 
they  have  succeeded  because  they  have  tried  to  do 
more  than  was  expected  of  them.  They  waited  until 
the  whistle  blew  before  they  put  away  their  tools,  while 
the  unsuccessful  man  is  he  who  had  his  coat  on  before 


INTRODUCTION  41 

it  stopped.  To  express  the  same  idea  in  another  way, 
the  person  who  is  working  for  himself  may  have 
immediate  success  but  after  a  time  the  unselfish  person 
easily  outstrips  him  in  the  race  to  success.  Esprit  de 
corps  must  be  well  developed  in  our  group  of  occupation 
workers  if  the  work  is  to  be  truly  successful.  It  is  im- 
portant to  emphasize  that  occupation  is  a  therapeutic 
measure  and  should  be  carried  on  in  a  way  most  help- 
ful to  the  patient.  The  monetary  value  of  his  work  is  a 
minor  consideration,  not  to  be  ignored  for  many  reasons, 
the  chief  of  which  is  the  good  effect  upon  the  patient  when 
he  knows  that  he  is  producing  something  of  value.  The 
patient's  mental  welfare,  however,  should  not  be  sac- 
rificed by  the  cultivation  of  stereotyped  habits  because 
he  has  shown  special  ability  in  the  making  of  a  particular 
article. 

It  is  unfortunate  that  some  hospital  superintendents 
cannot  see  the  benefits  which  may  be  derived  from  oc- 
cupation properly  carried  out  and  will  do  little  or  nothing 
to  aid  the  work.  In  a  hospital  where  such  a  man  is  head 
it  is  impossible,  of  course,  to  formally  organize  the  work 
as  has  been  suggested  above,  but  if  a  physician  or  nurse 
is  really  a  believer  in  occupation  therapy  it  is  always  easy 
to  so  employ  the  patients  that  a  demonstration  of  a 
more  quiet  ward  with  a  more  rapid  improvement  in 
individual  patients  may  serve  as  an  object  lesson  to  any 
but  the  most  bigoted.  After  the  prejudiced  superintend- 
ent has  been  convinced  it  is  usually  possible  to  inaugurate 
a  more  formal  organization  of  the  work. 

It  is  well  not  to  attempt  too  much  in  the  beginning, 
and  to  be  content  to  grow  slowly.  The  organization  of 
classes  of  various  sorts  in  the  wards  may  perhaps  be 
the  initial  effort,  followed  by  other  occupations  which 
require  that  .they  be  carried  on  in  shops  located  away  from 
the  wards.  Local  conditions  will  necessitate  particular 
arrangements  so  that  it  is  impossible  to  give  specific 
directions  for  inaugurating  occupational  work  here,  but 
as  a  rule  it  is  best  to  begin  occupation  for  women  in 


42  RECONSTRUCTION   THERAPY 

some  such  fashion  as  has  been  suggested  by  Dr.  Mary 
Lawson  Neff  (see  p.  62).  Dr.  Neff  has  had  an  unusual 
experience  in  systematizing  occupational  work  in  state 
hospitals  and  speaks  with  the  voice  of  authority.  Men 
may  be  started  in  small  groups  at  outside  tasks  such  as 
the  care  of  certain  parts  of  the  grounds  or  various  chores. 
Individual  patients  may  be  induced  to  take  up  some 
special  craft  such  as  crocheting  or  knitting  for  the  women, 
or  whittling  for  the  men.  The  example  of  these  may  be 
contagious  so  that  a  class  may  be  formed.  From  such  a 
beginning  the  development  of  other  crafts  often  follows. 
If  one  has  thought  much  of  occupation  and  has  even  in 
part  mastered  its  principles  but  few  suggestions  are 
required  to  point  the  way  to  its  inauguration. 


It  is  emphasized  that  anything  that  diverts  the  patient 
from  unhealthy  thought  is  to  be  classed  as  occupation. 
Various  names  are  given,  such  as  occupation,  diversion, 
diversional  occupation,  occupational  diversion,  occupa- 
tion and  amusement,  employment,  work  cure,  occupa- 
tional therapy,  and  ergotherapy  (epyov  =  work;  depaireia  = 
therapy).  The  last  is  probably  the  best,  and  certainly 
the  most  scientific  term,  but  as  yet  has  not  come  into 
sufficiently  general  use,  and  the  more  simple  term  occupa- 
tion will  probably  be  used  for  some  time.  As  has  been 
shown  in  the  foregoing  chapter  the  term  occupational 
therapy  is  also  applied  to  physical  exercises  which  have 
as  their  object  the  development  of  impaired  functions, 
but  it  has  also  been  shown  that  even  here  the  mental 
side  is  important. 

Recently  there  has  been  a  tendency  to  specialize  this 
subject  and  it  may  be  said  to  be  divided  into  invalid 
occupation,  occupational  therapy,  and  vocational  and 
revocational  education. 

Invalid  occupation  may  be  defined  as  consisting  of  the 
means  employed  to  make  the  invalid  contented  and  so 
more  co-operative,  and  which  have  no  further  object, 
such  as  mental  or  physical  training.  It  is  intended 
chiefly  to  divert  and  amuse,  keeping  the  mind  of  the 
patient  from  dwelling  upon  his  illness  and  possibly  devel- 
oping hypochondriacal  ideas.  In  certain  cases,  therefore, 
the  means  of  invalid  occupation  may  become  of  thera- 
peutic importance. 

Occupational  therapy  has  as  its  object  the  restoration 
of  physical  or  mental  functions  by  means  of  carefully 
planned  work,  exercise  or  amusements.  It  aids  in  the 

43 


44  RECONSTRUCTION    THERAPY 

recovery  of  disturbed  mental  functions  by  training  in 
concentrating  attention,  stimulating  association,  and 
diverting  from  unhealthy  thoughts. 

By  vocational  education  we  mean  the  training  neces- 
sary to  enable  the  individual  to  pursue  a  gainful  vocation. 
In  the  case  of  the  crippled  this  means  that  remain- 
ing limbs  must  be  educated  to  assume  the  functions 
of  those  missing,  as  when  a  right-handed  individual  learns 
to  use  his  left  for  the  same  movements,  or  where  a  laborer 
is  taught  a  trade,  etc.  Theoretically  it  is  not  the  func- 
tion of  the  ergotherapeutist  to  carry  on  vocational  train- 
ing, but  as  the  ordinary  vocational  technician  has  not 
the  special  knowledge  necessary  to  develop  either  the 
physically  or  mentally  handicapped,  it  is  necessary  for 
the  occupation  teacher  to  train  the  patient  in  the  funda- 
mentals of  a  craft  or  vocation  and  so  fit  him  to  be  cap- 
able of  receiving  instruction  from  the  technician. 

Revocational  education  means  that  the  patient  is 
taught  the  best  and  most  efficient  methods  of  using  his 
natural  capabilities,  or  the  use  of  prosthetic  appliances 
and  other  apparatus,  in  order  best  to  pursue  a  former 
vocation.  The  so-called  amusements  are  sometimes  the 
best  means  of  stimulating  a  patient's  mental  activities. 
For .  example,  those  in  charge  of  institutions  having 
libraries  wonder  how  it  was  ever  possible  to  get  along 
without  one,  and  Miss  Edith  Kathleen  Jones,  who  has 
done  more  to  impress  the  value  of  the  library  as  a  re- 
medial agent  upon  us  than  any  other  one  person,  has  writ- 
ten as  follows: 

"The  Superintendent  of  one  of  our  large  private  hos- 
pitals for  the  insane  recently  made  the  remark  that  if 
he  were  obliged  to  give  up  either  the  library  or  the  handi- 
crafts department,  he  would  unhesitatingly  choose  to 
keep  the  former.  His  reason  was  this:  That  there  are 
always  many  patients  who  cannot  be  roused  to  any  great 
interest  in  arts  and  crafts  work,  while  there  are  very  few 
who  will  not  read,  or  at  least  look  at  books  of  pictures." 

While  this  is  perfectly  true  for  our  private  or  incor- 


WHAT    OCCUPATION    IS  45 

porated  hospitals  it  must  be  remembered  that  in  our  state 
hospitals  there  are  many  patients  who  care  nothing  for 
reading,  and  some  who  do  not  know  how  to  read.  Oc- 
cupation may  be  quite  as  valuable  a  therapeutic  agent 
in  these  cases  as  in  the  better  educated  but  other  means 
than  the  library  must  be  found  for  applying  it.  For- 
tunately, there  may  be  many  other  places  of  amuse- 
ment, such  as  the  baseball  diamond,  bowling  alleys,  gym- 
nasium, etc.  When  used  intelligently  and  in  such  a 
way  as  to  create  interest  in  them;  these  may  be  of  such 
value  in  arousing  the  interest  of  patients  and  diverting 
them  from  their  morbid  thoughts  that  the  physicians 
wonder  how  it  was  possible  that  patients  recovered 
without  them. 

But  all  of  these  places  may  have  little  value  unless 
they  are  in  charge  of  persons  who  have  a  keen  interest  in 
the  success  of  their  especial  department  and  an  enthu- 
siasm that  is  contagious.  The  Director  can  and  should 
do  much  to  stimulate  such  enthusiasm. 

In  the  Standard  Dictionary  there  are  several  definitions 
given  under  the  word  occupation,  one  of  which  is  as 
follows:  "3.  The  state  of  being  employed,  occupied, 
or  kept  busy  in  any  way;  as,  continual  occupation  is 
wearisome."  This  definition  is  an  excellent  one  for 
our  purpose  and  we  may  well  adopt  as  our  motto  "Keep 
busy."  The  excellence  of  this  last  was  impressed  upon 
me  not  long  ago  by  a  former  patient  at  the  Sheppard 
and  Enoch  Pratt  Hospital  who  came  to  us  suffering  from 
an  attack  of  depression.  After  much  urging  she  was 
finally  induced  to  do  things  which  quite  rapidly  brought 
about  an  improvement. 

In  a  letter  the  patient  says:  "Dr.  Dunton,  I  wish  I 
could  see,  and  talk  with  you,  now  that  I  am  well,  and  tell 
you  how  above  all  things  else,  I  believe  the  "Keep 
busy  all  the  time"  plays  the  most  important  part  in 
restoring  your  patients  to  normal  health.  I  shall  never 
cease  to  thank  you  for  your  part  in  getting  me  interested 
in  work." 


46  RECONSTRUCTION    THERAPY 

But  with  this  divertisement  let  us  return  to  the 
dictionary  and  take  up  the  remainder  of  our  quotation. 
"  Continual  occupation  is  wearisome."  So  it  is,  we 
willingly  admit  it,  and  when  our  therapeutic  occupation 
becomes  wearisome  it  defeats  its  own  aims.  How  this 
may  be  avoided  is  considered  more  fully  on  the  following 
pages,  so  that  it  need  not  be  taken  up  at  present,  but 
it  may  not  be  amiss  to  discuss  here  of  what  in  general 
a  normal  man's  or  woman's  life  should  consist.  It  sim- 
plifies matters  if  we  admit  that  in  the  partnership  known 
as  marriage  the  man  is  in  charge  of  the  activities  which 
lead  to  a  gainful  income,  the  woman  is  in  charge  of  those 
activities  which  lead  to  a  disbursement  of  a  whole  or 
part  of  the  income  for  the  purposes  of  supporting  life, 
etc.,  and  that  each  partner  is  equally  important  economic- 
ally considered.  Each  partner  has  certain  routine  duties : 
first,  those  connected  with  personal  care,  such  as  washing, 
dressing  and  eating,  second,  those  concerned  with  the 
welfare  of  others,  such  as  household  tasks  or  business 
details.  Of  the  first,  it  is  possible  to  make  them  pleasant 
or  the  reverse.  The  same  may  be  said  of  the  second 
which  may  require  a  considerable  personal  effort  to 
keep  from  becoming  somewhat  stereotyped.  The  first, 
however,  are  more  apt  to  become  automatic  acts  and 
for  this  reason  cause  less  mental  fatigue.  One's  daily 
*  duties  also  require  a  certain  amount  of  social  intercourse. 
In  a  rather  crude  way  this  sums  up  an  individual's 
daily  life.  It  may  be  like  that  of  the  milkmaid's  in 
the  comic  opera, 

"Her  life's  one  endless  round,  'tis  said, 
Of  rising  and  working  and  going  to  bed." 

It  takes  but  a  little  thought  to  convince  one's  self  that 
this  is  true  for  every  station  in  life.  For  the  primitive 
man  and  woman  as  well  as  the  most  cultivated. 

In  order  that  one's  life  should  not  become  such  a  dull 
affair  we  must  order  it  in  some  fashion.  The  housewife, 
whose  routine  duties  are  partly  mental  and  partly 


WHAT    OCCUPATION   IS  47 

manual  and  of  such  a  nature  that  they  may  easily  become 
automatic,  must  have  diversion  by  other  occupations 
which  give  a  change  such  as  a  study  of  some  author, 
artist,  or  other  intellectual  diversion  either  by  herself 
or  with  others,  as  at  her  club  or  society,  and  some 
manual  diversion  such  as  embroidery,  or  some  similar 
work  which  requires  more  concentration  of  attention, 
and  therefore  arouses  greater  interest  than  does  the  more 
automatic  plain  sewing  which  is  a  part  of  her  house- 
keeping duties. 

The  man's  routine  duties  as  a  rule  are  less  diversified 
than  the  woman's,  and  his  recreations,  therefore,  should 
be  more  positively  either  manual  or  mental  than  the 
woman's.  For  example,  a  lawyer's  or  an  editor's  work 
is  chiefly  mental  and  his  recreation  should  therefore  be 
some  physical  activity  such  as  golf,  tennis,  horseback 
riding,  or  gardening.  A  hod  carrier  on  the  other  hand 
should  be  encouraged  to  take  up  a  reading  course  which 
will  develop  him  into  something  more  than  the  machine 
which  his  work  tends  to  make  of  him. 

To  recapitulate  these  somewhat  discursive  remarks,  a 
physical  occupation  should  have  its  antidote  in  mental 
work  and  vice  versa.  While  much  more  might  be  said 
on  this  subject  it  is  believed  to  be  unnecessary  to  those 
who  are  at  all  familiar  with  occupational  therapy.  To 
those  who  have  neglected  its  study  and  who  may  be 
unconvinced  by  the  above  even  after  an  examination 
of  their  own  experience,  I  would  suggest  that  a  brief 
study  of  the  subject  be  made,  as  I  am  very  sure  that  no 
one  can  conscientiously  investigate  the  results  that  have 
been  achieved  by  means  of  this  method  of  treatment 
without  being  convinced  of  its  efficacy.  This  is  not  to  be 
wondered  at  when  we  realize  that  the  work  cure  is  really 
but  a  method  of  bringing  the  patient  back  to  a  normal 
way  of  living.  The  French  have  a  delightful  little  poem 
which  has  been  translated  by  Du  Maurier  in  Trilby, 
as  follows: 


48  RECONSTRUCTION    THERAPY 

A  little  work,  a  little  play, 

To  keep  us  going — and  so,  good-day! 

A  little  warmth,  a  little  light, 

Of  love's  bestowing — and  so,  good-night! 

A  little  fun  to  match  the  sorrow 

Of  each  day's  growing — and  so,  good-morrow! 

A  little  trust  that  when  we  die 

We  reap  our  sowing!     And  so — good-by! 


'  This  very  charmingly  sums  up  of  what  our  lives  should 
consist,  but  they  may  be  amplified  if  we  "hitch  our 
wagon  to  a  star, "  ever  keep  it  in  sight  and  plod  patiently 
toward  it.  We  may  reach  our  goal  sooner  by  striving 
harder,  by  concentrating  on  one  thing,  but  it  will  be  at 
the  sacrifice  of  something.  The  man  with  the  broad  view 
of  life  which  comes  from  reading  on  many  subjects, 
and  learning  to  do  many  things,  may  never  achieve 
the  fame  which  another  reaches  through  concentrating 
all  of  his  energies  upon  the  mastery  of  one  subject,  but 
existence  will  hold  much  more  of  happiness  and  in  the 
afternoon  of  his  life  he  is  not  so  liable  to  feel  weariness 
and  lack  of  ambition.  As  some  one  has  quaintly  said 
regarding  a  general  interest  in  a  number  of  things 
"When  I  break  my  doll  I  still  have  mud  pies  to  play 
with."  It  is  a  fairly  common  thing  for  psychiatrists 
to  have  under  their  care  men  in  the  forties  who  have 
achieved  the  height  of  their  ambition,  usually  business 
success,  and  who  realize  that  their  limitations  prevent 
their  going  higher.  Having  no  other  interests,  life  be- 
comes a  dull  routine,  like  the  milkmaid's,  and  they  suffer 
an  attack  of  depression.  Had  they  taken  a  broader  view 
of  life  with  wider  interests  the  attack  might  have  been 
avoided.  Such  individuals  have  to  learn  "how  to  live." 
That  is  the  essential  part  of  their  treatment.  Occupation 
by  broadening  their  interests,  is  naturally  the  best  method 
of  accomplishing  this. 


WHAT   OCCUPATION   IS  49 

Even  at  the  risk  of  making  myself  wearisome,  I  cannot 
leave  this  subject  without  quoting  from  a  splendid  arti- 
cle by  Dr.  John  H.  Finley  on  "The  Wisdom  of  Leisure"1 
which  should  be  read  by  everyone  desirous  of  making 
the  most  of  his  life.  He  says:  "We  all  have  or  should 
have  a  triune  day:  a  "work  day"  in  which  we  do  our  share 
of  the  world's  work,  a  "sleep  day"  in  which  we  must 
physically  rest,  and  a  "leisure  day,"  which  is  as  long  as 
either  of  the  others  for  most  people,  if  they  but  knew  it, 
a  third  day  in  which  to  cultivate  our  real  selves,  to  ap- 
proach our  "possible  perfection." 

"And  I  repeat  an  observation  which  I  have  often  made, 
that  the  real  test  of  living  is  what  we  do  with  the  third 
of  these  days,  which  is  so  frequently,  almost  generally, 
looked  upon  as  the  idle  margin  of  the  "work  day" 
or  the  drowsy  margin  of  the  "sleep  day." 

"We  cannot  doubtless  (despite  the  reported  experi- 
ence of  a  nameless  Harvard  professor),  shorten  much 
our  "sleep,  day."  We  cannot  perhaps,  shorten  much 
our  "work  day,"  unless  indeed  we  are  willing  to  live  more 
simply.  It  remains  to  make  the  most  of  our  "freedom 
day,"  to  practice  intellectual,  moral,  spiritual  efficiency 
here  even  as  we  attempt  higher  economic  efficiency  in 
the  "work  day." 

"Most  of  us  waste  enough  leisure  time  to  make  our- 
selves great  musicians,  artists,  scholars,  poets,  able  to 
minister  our  avocation  to  human  happiness  even  beyond 
that  which  we  can  do  in  our  vocation." 

1  The  Playground,  Vol.  ix,  p.  335,  January,  1916. 


CHAPTER  III 

THE  QUALIFICATIONS  OF  AN  OCCUPATION 
DIRECTOR 

The  qualifications  necessary  to  make  a  good  occupa- 
tion director  are  many  and  cannot  be  simply  told.  He 
must  have  a  vast  amount  of  Tjatigjicje  if  for  no  other 
reason  than  to  serve  as  a  shining  example  to  the  various 
teachers  who  work  under  him.  If  he  does  not  possess 
patience  he  is  apt  to  be  too  anxious  to  show  results  and 
to  be  discontented  with  the  slow  progress  that  is  nec- 
essary for  the  proper  restoring  of  mental  and  physical 
functions  which  comes  through  work.  This  discontent 
is  easily  and  unconsciously  transmitted  to  the  teachers. 
He  must  possess  a  considerable  knowledge,  in  theory 
at  least,  of  many  crafts  and  occupations  in  order  that  the 
patient's  interest  may  be  attracted  and  their  occupation 
prevented  from  becoming  toil.  Tact  is,  of  course,  a 
necessary  qualification  in  every  physician  but  is  even 
more  necessary  in  the  occupation  director.  He  must  pos- 
sess what  is  called  business  ability  in  order  that  his  de- 
partment may  be  conducted  as  economically  as  possible, 
so  that  the  powers  that  be  will  not  shut  down  on  this 
most  important  therapeutic  measure.  Above  all  he 
must  possess  what  has  been  called  "the  precious  gift 
of  inspiring  others,"  for  occupation  cannot  be  carried 
on  single  handed  and  unless  this  gift  be  his  those  assist- 
ing the  director  will  be  unable  to  do  their  best. 

Depending  upon  whether  his  duties  are  in  a  mental 
or  physical  (orthopedic)  hospital  will  it  be  necessary 
for  the  director  to  specialize  in  methods  which  will  stimu- 
late mental  or  physical  functions.  When  dealing  with 
mental  or  nervous  patients  he  must  be  a  good  psychi- 

50 


THE   QUALIFICATIONS    OF   AN    OCCUPATION    DIRECTOR    51 

atrist  that  he  may  know  what  mental  functions  are  most 
impaired  and  how  they  may  best  be  restored.  On  the 
other  hand,  the  director  who  is  chiefly  concerned  with 
the  restoration  of  physical  functions  must  specialize 
upon  what  is  known  as  kinesitherapy  (xu'Tjem  =  motion, 
dfpocjreLa  =  cure)  or  treatment  by  movement.  This 
last  has  come  into  considerable  prominence  during  the 
Great  War  and  is  discussed  briefly  in  Chapter  XII. 
It  is  extremely  important,  however  he  may  specialize, 
that  the  occupational  director  know  something  of  psy- 
chology, and  especially  of  that  part  which  deals  with 
reactions  and  mental  adjustments.  This  is  quite  as 
necessary  for  the  one  dealing  with  physical  as  with  mental 
cases.  I  have  recently  (1918)  seen  a  man  eminent 
in  vocational  training  make  a  failure  of  occupational 
therapy  in  a  government  hospital,  chiefly,  I  believe,  be- 
cause he  did  not  know  enough  of  the  psychology  of 
every-day  life  to  present  the  subject  properly  to  the  pa- 
tients. Some  persons  seem  to  acquire  this  knowledge 
of  y^actions-and  adjustments  without  any  formal  study 
of  psychology,  in  which  case  we  usually  say  that  they 
have  tact.  Others  must  acquire  this  by  training  and 
study. 

The  above  are  the  main  requisites  of  an  occupation 
director,  but  the  possession  of  a  fertility  of  invention, 
a  vast  amount  of  energy,  an  artistic  sense  of  form  and 
color,  and  other  faculties  which  tend  to  make  him  a 
broad-minded,  cultivated  man  will  enable  him  to  fill  his 
position,  rather  than  merely  to  occupy  it. 

It  seems  needless  to  say  that  it  is  essential  for  the 
director  to  have  a  strong  interest  in  this  form  of  therapy; 
for  without  it  he  cannot  have  that  precious  gift  of 
inspiring  others,  and  the  different  forms  of  work  will 
lag  and  become  stereotyped  in  character.  This  last 
is  a  defect  which  must  be  constantly  guarded  against 
and  the  director  must  be  ever  alert  to  stimulate  his 
assistants  with  suggestions  of  special  methods  to  be  used 
with  certain  patients  in  order  to  arouse  their  interest  as 


52  RECONSTRUCTION    THERAPY 

quickly  as  possible,  of  solutions  for  various  problems, 
and  in  many  other  ways  to  keep  active  the  interest 
of  those  who  are  aiding  him. 

He  must  have  fertility  of  invention  in  order  that  he 
make— suggestions  -for  occupying  patients  who  have  per- 
haps done  many  things  without  showing  any  interest 
in  them.  In  such  cases  it  is  necessary  to  keep  on  trying 
something  new  until  at  last  the  work  is  found  which 
engrosses  the  patient's  attention  and  so  stirs  up  interest. 
This  may  be  something  bizarre,  something  familiar 
or  something  unfamiliar,  something  difficult  or  something 
extremely  simple.  The  following  experience  serves 
to  illustrate  this.  A  woman  with  anxious  depression 
was  extremely  difficult  to  occupy.  One  day  I  asked 
her  as  a  personal  favor  to  fold  some  papers  for  me 
and  the  nurse  noted  that  she  seemed  to  be  interested, 
so  that  when  material  was  present  she  was  always  asked 
to  do  this  work.  As-  often  happens,  the  patient  then 
developed  the  idea  that  the  folding  was  not  to  serve  a 
useful  purpose  and  was  only  being  given  her  to  keep 
her  occupied.  Considerable  protestations  on  my  part 
did  not  seem  to  convince  her,  but  when  she  saw  holiday 
menus  which  she  had  folded  in  actual  use  and  received 
a  scolding  for  not  doing  other  folding  neatly,  this  idea 
disappeared.  It  was,  however,  difficult  to  find  enough 
paper  folding  to  occupy  the  patient  properly  so  that 
recourse  was  had  to  other  work.  She  was  given  a 
number  of  journals  to  take  apart  for  binding,  that  is, 
remove  the  wire  stitching,  but  could  never  be  induced 
to  do  it.  She  would  arrange  the  scrap  books  of  amuse- 
ment posters,  and  of  menus,  and  seemed  to  take  some 
interest  in  these,  but  nothing  helped  her  so  much  as  the 
paper  folding,  probably  because  she  felt  that  here  was 
something  that  she  could  do  well.  Later  on  as  she  im- 
proved she  did  some  cross  stitch  work  but  frequently 
pulled  it  out  because  she  feared  it  was  not  right,  and  still 
later  did  some  crocheting.  Unfortunately  the  patient 
was  removed  from  care  before  convalescence  was  well 


THE   QUALIFICATIONS    OF   AN    OCCUPATION    DIRECTOR    53 

established  and  we  were  not  able  to  further  develop  the 
work  cure  in  her  case.  I  often  cudgelled  my  brain  to 
devise  paper  folding  for  her  in  some  form,  and  usually 
selected  a  holiday  menu  which  required  folding  in  order 
to  keep  her  at  work,  besides  trying  to  think  of  some  other 
occupation  which  would  interest  her.  I  have  seen  some 
of  my  assistants  work  over  other  patients  in  the  same  way 
and  have  been  asked  to  suggest  some  form  of  work  which 
they  should  try. 

The  director  should  have  some  artistic  sense  of  form 
and  color;  if  for  nothing  else,  to  prevent  the  making  of 
some  of  the  horrible  things  which  many  patients  desire 
to  perpetrate.  Such  things  give  but  little  pleasure  to 
anyone  but  the  maker  and  may  give  aesthetic  offense 
to  many.  They  are  also  a  waste  of  good  material, 
which  is  not  a  minor  consideration.  It  is  usually  easy 
to  make  suggestions  which  will  not  be  offensive  and  which 
will  educate  the  patient  to  better  appreciate  what  is 
good  in  form  and  color.  Often  the  bizarre  attracts 
us  by  daring  but  we  soon  tire  of  it.  Recent  instances 
are  the  cubist  and  futurist  styles  of  painting,  and  the 
so-called  magpie  decoration  in  which  black  and  white 
are  spatially  equal  and  hence  colorfully  inharmonious. 
In  every  hospital,  indeed  in  every  community,  there  are 
individuals  who  delight  in  useless  work,  such  as  the 
carpenter  who  in  his  playtime  made  a  full-grown  chair 
by  gluing  toothpicks  together,  or  the  man  who  papered 
a  room  with  cancelled  postage  stamps,  or  the  more 
numerous  individual  who  whittles  still  more  numerous 
wooden  chains  from  sticks  of  wood.  Such  work  is  soul 
clogging  and  therefore  clogs  the  wheels  of  progress.  In 
order  to  criticize  and  correct  such  nefarious  practices 
the  director  must  himself  learn  what  is  good,  beautiful, 
and  true  by  reading  and  observation.  He  must  be 
careful  not  to  be  so  strongly  attracted  to  some  particular 
school  of  art  that  he  himself  becomes  a  faddist,  and  so 
defeats  the  end  toward  which  he  has  aimed,  that  of 
making  himself  broad  minded  and  well  informed.  An 


54  RECONSTRUCTION   THERAPY 

admirable  exposition  of  the  chief  characteristics  of 
beauty  may  be  found  in  Mentor  No.  102. 

"No  word  in  the  language  is  more  abused  than 
'beauty.'  A  pretty  thing  is  a  thing  of  beauty;  a  pretty 
picture  is  a  thing  of  beauty;  and  so  following.  Lacking 
a  proper  descriptive  term  for  anything  attractive,  we, 
too  often,  employ  the  word  'beauty. '  What  term  have 
we  then  with  which  to  pay  tribute  to  true  beauty? 

"The  real,  final  test  of  beauty  is  that  it  wears  well — 
not  in  a  material  way,  but  in  the  qualities  that  are  truly 
beautiful.  The  rose  is  fragile  material  and  its  life  is 
brief,  but  rose  beauty  is  lasting  and  rose  fragrance 
clings  sweetly  to  the  memory — so  that  the  rose  has 
become  a  synonym  of  beauty.  The  message  of  true 
beauty  is  enduring  and,  oft  repeated,  grows  in  charm. 
'A  thing  of  beauty  is  a  joy  forever.' 

"A  distinguishing  attribute  of  true  beauty  is  authority. 
A  thing  of  beauty  bears  on  its  very  forefront  the  stamp 
of  authority.  It  does  not  plead  for  recognition — it 
commands  it.  The  snow-capped  summit  at  sundown, 
the  Madonna  face  on  a  master's  canvas,  the  poet's 
'lofty  rhyme,'  the  fragrant  flower,  the  harmonious 
symphony,  the  'frozen  music'  of  architecture — count- 
less varied  forms  of  beauty  in  nature,  art  and  life  ask 
no  favor  nor  do  they  play  to  the  fancy  of  the 
moment.  Created  in  intelligence,  sincerity  and  truth, 
and  inspired  by  lofty  devotion,  they  compel  a  lasting 
homage." 

I  feel  that  I  have  very  inadequately  expressed  what  I 
desire  as  to  the  qualifications  of  a  director  and  yet  do  not 
wish  to  discourage  anyone  by  what  may  appear  to  be 
rather  severe  requirements,  for  it  must  be  remembered 
that  local  conditions  may  make  one  person  extremely 
valuable  whereas  in  a  d  fferent  situation  he  may  be  a 
round  peg  in  a  square  hole.  It  may  be  comforting  to 
recall  that  not  all  holes  are  square,  neither  are  all  pegs 
round,  and  usually  by  wobbling  about  a  bit  pegs  and 
holes  will  be  fitted. 


CHAPTER  IV 
THE  DUTIES  OF   THE  OCCUPATION  DIRECTOR 

As  has  been  previously  stated,  the  occupation  director 
is  usually  one  of  the  senior  physicians  whose  years  of 
service  has  brought  to  him  a  knowledge  of  the  conditions 
and  requirements  of  his  hospital  so  that  he  is  able  to 
co-ordinate  and  direct  all  of  the  institution's  occupational 
activities.  While  he  may  be  keenly  interested  in  the 
work,  it  may  happen  that  these  duties  take  up  more  time 
than  can  be  spared  from  his  other  professional  and  ad- 
ministrative duties.  On  the  other  hand,  if  the  director 
has  not  had  a  medical  training  it  has  been  found  that 
there  will  be  a  lack  of  sympathy  between  the  medical 
staff  and  the  occupational  department  so  that  this  valu- 
able therapeutic  agent  is  not  used  so  well  as  it  should  be. 
It  is  unfortunate  that  many  physicians,  usually  the  in- 
experienced, do  not  recognize  the  great  value  that  well- 
regulated  occupation  may  have  in  aiding  in  the  recovery 
of  their  patients  and  do  not  take  pains  to  prescribe  it 
judiciously.  For  this  reason  alone,  if  for  no  other,  it 
is  believed  that  the  director  should  be  one  of  the  senior 
physicians,  who  should  at  rounds,  conference,  and  else- 
where, instruct  the  juniors  as  to  the  value  of  occupation 
and  how  it  may  be  best  applied.  If  necessary  to  curtail 
the  director's  duties,  let  it  be  those  which  are  profitless 
to  him  and  his  patients,  such  as  unnecessary  interviews 
with  the  friends  of  patients  and  other  routine  work. 

The  fact  should  never  be  lost  sight  of  that  the  function 
of  the  mental  hospital  is  to  heal  sick  minds,  and  that  even 
those  patients  classed  as  chronic  are  susceptible  of  im- 
provement by  properly  directed  therapeutic  measures. 
It  is  believed  by  many  that  occupation  is  the  most  valu- 

55 


56  RECONSTRUCTION    THERAPY 

able  single  agent  in  restoring  the  sick  mind  to  its  normal 
condition  and  it  would  seem  not  too  much  to  ask  that 
one  of  the  best  men  on  the  staff  be  given  direction  of 
this  valuable  therapeutic  measure. 

On  the  physical  side  of  occupational  therapy,  which 
has  become  more  prominent  since  the  Great  War,  the 
director  can  often  substitute  forms  of  occupation  to  take 
the  place  of  the  less  interesting  mechanotherapy.  This 
will  require  that  he  make  a  careful  study  of  many  crafts 
and  vocations,  and  especially  of  motion  study  that  he 
may  give  to  the  patient  work  which  will  interest  him  and 
at  the  same  time  give  the  required  physical  exercise. 

The  director's  first  duty  has  already  been  stated,  that 
of  instructing  the  younger  members  of  the  staff  in  the 
value  of  occupation  and  how  it  is  to  be  applied,  showing 
them  why  one  occupation  may  be  best  for  one  case  and 
a  different  one  for  another.  Just  as  the  clinical  director 
has  oversight  over  all  of  the  clinical  work  of  the  hospital 
and  is  the  arbiter  of  all  clinical  questions,  so  should  the 
occupation  director  have  charge  of  all  of  the  occupations 
and  industries,  and  decide  all  questions  concerning  this 
method  of  therapy. 

Elsewhere,1  in  a  manual  for  nurses,  certain  rules  have 
been  given  which  are  to  be  followed  when  patients  are 
to  be  occupied.  They  are  here  inserted  to  emphasize 
the  inference  from  the  above  that  when  occupation  is 
used  it  should  be  done  understandingly  and  not  in  a  hap- 
hazard way.  They  are  as  follows: 

1.  The  occupation  should  be  new — that  is,  something 
to  which  the  patient  is  not  accustomed,  in  order  to  ar- 
rest and  hold  his  attention. 

2.  One  occupation  should  not  be  followed  to  the  point 
of  fatigue.     A  change  of  occupation  may  be  the  best 
form  of  rest,  as  throwing  a  ball  or  bean  bag  after  sitting 
over  leather  punching,  or  taking  a  walk  after  being  at 
work  at  a  loom. 

1  Occupation  Therapy.  A  Manual  for  Nurses.  Phila.,  1915, 
W.  B.  Saunders  Co. 


THE    DUTIES    OF    THE    OCCUPATION    DIRECTOR  57 

3.  The  work  should  be  useful  and  the  patient  should 
be  shown  what  this  use  is.     Avoid  aimless  work. 

4.  It  should  preferably  lead  to  an  enlargement  of  the 
patients  mental  horizon,  and  a  study  and  interest  in 
associated  things.     It  is  for  the  reason  that  the  nurse 
may  appreciate  the  greater  interest  in  an  occupation, 
if  such  are  known,  that  the  historical  and  other  facts 
have  been  introduced  in  this  book. 

5.  The  nurse  should   participate  in  the   occupation 
and  show  an  interest  in  it. 

6.  The  patient  should  be  encouraged  by  praise,  and 
criticism  should  be  given  sugar  coated. 

7.  It  is  better  that  the  patient  do  bad  work  than  none 
at  all. 

It  is  believed  that  these  rules  summarize  the  basic  prin- 
ciples of  ergotherapy  and  afford  a  convenient  means  of 
inculcating  these  principles  in  the  inexperienced  medical 
officer. 

According  to  the  interest  and  co-operation  of  his  as- 
sociates from  the  Superintendent  down,  the  work  of  the 
director  will  be  difficult  or  comparatively  easy.  If 
he  believes  that  sympathy  is  lacking  for  his  work  he 
must  remember  that  many  persons  are  Missourians  and 
that  the  burden  of  proof  as  to  its  value  is  upon  his 
shoulders.  If  he  carries  on  the  work  conscientiously 
and  understandingly  it  will  not  be  long  before  the 
results  attained  will  convince  the  most  skeptical. 

He  will  next  organize  the  various  departments  and 
shops  and  convince  those  in  charge  of  them  that  the  pri- 
mary object  of  their  existence  is  to  get  patients  well. 
If  the  carpenter  or  blacksmith  or  plumber  feels  that  he 
cannot  be  bothered  with  teaching  and  watching  patients, 
and  the  superintendent  has  the  same  opinion,  the  di- 
rector should  eliminate  all  thought  of  using  such  a 
department  as  a  means  of  occupation,  and  should 
substitute  other  industries  or  crafts  to  take  their  place. 

Someone  should  be  in  charge  of  each  of  the  industries 
and  responsible  for  it.  This  person  we  may  for  con- 


58  RECONSTRUCTION    THERAPY 

venience  call  the  teacher,  for  such  will  be  his  or  her  chief 
duty.  He  should  also  keep  a  record  of  the  patient's 
work,  of  his  interest,  power  of  concentration  (attention), 
skill,  etc.,  which  record  should  form  a  part  of  the  patient's 
history  or  record.  In  order  that  such  records  may  be 
well  kept  the  director  should  instruct  the  teachers  in  the 
principles  of  occupation  therapy.  These  teachers  should 
make  out  requisitions  for  supplies  which  should  be 
approved  by  the  director  before  being  sent  to  the  pur- 
chasing agent.  It  is  believed  by  many  that  nurses 
make  the  best  teachers  on  account  of  their  training  and 
better  understanding  of  patients,  even  though  their 
technical  knowledge  of  the  craft  may  not  be  equal  to 
another  who  is  not  trained  in  nursing  but  has  been  well 
trained  in  a  craft.  It  should  be  remembered  that  the 
primary  purpose  of  occupation  is  to  aid  the  patient's 
recovery  and  the  development  of  craftsmen  is  of  less 
importance.  The  question  of  the  training  of  nurses  in 
occupational  methods  is  discussed  in  another  chapter 
(p.  78). 

The  director  should  also  arrange  for  the  saving  of 
waste  from  one  department  which  can  be  utilized  in 
another,  and  for  its  delivery.  This  subject  and  that 
of  the  disposal  of  manufactured  products  is  considered 
more  fully  in  Chapter  VI. 

The  director  should  pay  frequent  visits  to  the  various 
shops  and  encourage  other  members  of  the  staff  to  do  the 
same,  both  to  personally  observe  how  the  patients  work 
and  what  progress  they  are  making,  and  to  encourage 
both  the  teacher  and  the  patients  by  their  interest. 

It  is  a  good  plan  to  have  frequent  conferences  with 
the  teachers  (preferably  on  other  occasions  than  the 
above-mentioned  visits  so  that  the  work  of  the  class  will 
not  be  too  much  interrupted)  in  order  that  details  of 
work  and  plans  may  be  considered,  and  also  that  encour- 
agement may  be  given,  for  it  must  be  remembered  that 
there  is  much  about  teaching  and  especially  of  mental 
cases  that  is  discouraging.  Results  seem  very  slow  in 


THE    DUTIES    OF   THE    OCCUPATION    DIRECTOR          59 

appearing  to  those  who  are  closely  concerned  with  their 
development. 

An  occasional  conference  of  the  director  with  all  of 
the  teachers  will  have  the  effect  of  developing  a  spirit  of 
co-operation.  At  this  general  meeting  plans  can  be  dis- 
cussed and  such  a  conference  should  always  be  held  to 
arrange  for  the  bazaar,  at  which  the  products  of  the 
shops  are  sold. 

Teachers  should  be  encouraged  to  visit  other  hospitals 
to  observe  their  methods  and  also  to  study  to  improve 
themselves. 

To  sum  up  the  main  duties  of  the  occupation  director : 
Training  the  staff;  Training  the  teachers;  Arranging 
for  the  purchase  of  supplies,  and  the  utilization  of  waste; 
Disposal  of  manufactured  products;  Supervision  of  the 
shops  and  conferences  with  the  teachers. 

To  these  should  be  added  the  direction  of  amusements 
and  the  occupational  training  of  nurses.  Both  properly 
belong  to  the  duties  of  the  occupation  director.  In 
some  hospitals  it  is  found  to  be  convenient  to  have  one 
director  of  occupation  for  both  men's  and  women's 
departments,  in  others  that  there  be  separate  directors. 
It  is  quite  possible  for  these  two  to  work  in  harmony  and 
sometimes  to  encourage  a  friendly  rivalry  which  is  in- 
spiring to  the  teachers.  As  a  rule,  however,  the  occupa- 
tions for  men  and  those  for  women  are  different  so  that 
there  need  be  no  clashing  of  interests. 

The  work  of  the  director  may  differ  considerably  in 
detail  in  the  state  hospital,  in  the  incorporated  hospital, 
in  the  private  hospital  and  in  the  psychiatric  clinic,  so 
that  some  comment  will  be  made  on  the  differences  which 
may  exist  in  each  of  these  as  affecting  the  duties  of  the 
director. 

THE  STATE  HOSPITAL 

In  a  state  hospital  the  number  of  patients  is  usually 
several  hundred  and  the  majority  of  them  belong  to  the 
chronic  class  in  whom  recovery  cannot  be  expected.  It 


60  RECONSTRUCTION    THERAPY 

has  been  found,  however,  that  by  proper  therapeutic 
measures,  and  occupation  is  the  most  valuable,  consider- 
able improvement  in  the  mental  condition  may  occur  so 
that  an  encouraging  number  can  leave  the  hospital  and 
live  in  their  homes,  or  elsewhere,  under  some  sort  of 
after  care.     The  occupation  director,  therefore,  has'not  a 
hopeless  task  before  him.     The  patient  population  com- 
prises all  classes  of  cases,  even  epileptics  in  the  majority 
of  states,  so  that  there  is  ample  opportunity  to  try  out 
the  effect  of  occupation  in  different  psychoses.     Another 
advantage  is  that  the  great  majority  of  the  patients  are 
accustomed  to  manual  work  and  there  is  not  the  necessity 
for  so  much  urging  to  induce  patients  to  work  as  exists 
in  private   and  incorporated  hospitals.     There  is  the 
disadvantage  that  a  great  many  tasks  must  be  done 
which  are  of  a  routine  character  and  which  ordinarily 
do  not  help  the  patients  who  do  them  because  they  tend 
to   become   stereotyped   acts.     This   tendency   can   be 
avoided  by  changing  the  patient  from  one  such  task  to 
another  at  fairly  frequent  intervals.     The  director  will 
also  have  difficulty  in  carrying  on  various  forms  of  handi- 
craft because  of  the  lack  of  funds  for  this  purpose.     It 
is  usual  to  find  a  number  of  so-called  industries  in  state 
hospitals  which  may  take  the  place  of  some  of  these 
handicrafts.     It  is  unfortunate  that  in  some  institutions 
the  desire  to  make  a  good  showing  and  turn  out  a  con- 
siderable  quantity   leads  to  an  overstirnulation  of  the 
willing  so  that  the  working  periods  are  too  long  and  the 
therapeutic  value  of  the  occupation  is  thereby  lessened. 
Another  unfortunate  tendency  is  to  put  the  patient  to 
work  at  his  trade  rather  than  at  something~with  which 
he  is  not  familiar.     As  a  consequence  the  patient  thinks 
that  if  he  is  well  enough  to  work  at  his  trade  at  the 
hospital,  he  is  well  enough  to  do  the  same  at  the  factory 
and  so  support  his  family.     He  can  see  no  reason  for  his 
detention,  is  apt  to  consider  himself  a  prisoner,  and  may 
develop  persecutory  ideas  against  the  physicians.     It  is 
undoubtedly  more  trouble  to  teach  shoemaking  to  a 


THF    DUTIES    OF   THE    OCCUPATION    DIRECTOR          61 

weaver  and  weaving  to  a  shoemaker  than  to  allow  each 
to  work  at  his  own  trade,  but  the  therapeutic  effect 
will  be  greater.  This  rule  must  be  broadly  construed, 
however,  for  it  is  easy  to  conceive  that  a  patient's  self 
esteem  and  confidence  in  himself  may  be  increased  by 
the  knowledge  that  he  is  as  able  to  do  skilled  work  as  be- 
fore he  became  ill.  Instances  are  also  quite  frequent  of 
patients  who  could  not  be  induced  to  do  anything  until 
taken  to  the  shops  where  they  saw  others  making  articles, 
and  using  tools  with  which  they  were  formerly  familiar. 
A  rather  amusing  example  was  given  by  a  speaker  at  a 
conference  who  told  of  a  weaver  who  could  not  be  occu- 
pied in  any  way.  He  would  sit  beside  a  loom  appar- 
ently quite  indifferent  to  what  was  going  on  about 
him.  Finally,  the  worker  next  to  him  got  into  difficulties 
one  day  and  was  rather  making  a  mess  of  things  when  the 
weaver  rose  to  his  feet,  pushed  the  worker  aside,  and 
straightened  out  the  difficulties.  After  this  he  became 
a  steady  attendant  at  the  shop. 

The  start  having  been  made,  however,  it  is  well  to  begin 
to  cultivate  the  patient's  interest  in  other  occupations. 

A  model  program  to  give  variety,  relieve  monotony, 
and  stimulate  the  mental  activities  of  the  patient  might 
read  something  like  the  following: 

7:00  A.  M.  Breakfast. 

8:00  Shop  (weaving,  shoe,  broom,  etc.). 

9 : 30  Calisthenics,  or  a  walk. 

10:00  Work  on  farm  or  lawn. 

11 : 30  Clean  up  for  dinner. 

12:00  Dinner. 

1:00  P.  M.  Shop  (shoe). 

2:30  Ball  practice. 

3:00  Shop  (weaving). 

4 : 30-5 :00     Occupation  on  the  ward. 

5:30  Supper. 

7 : 00  Entertainment. 

9:00  Bed. 

The  above  is  merely  intended  as  a  suggestion  and  will 
have  to  be  changed  to  suit  the  individual  case  and  the 
convenience  of  administration. 


62  RECONSTRUCTION    THERAPY 

Usually  the  industries  do  not  attempt  to  supply  more 
than  the  needs  of  the  hospital,  or  others  of  the  same 
state  system,  but  occasionally  the  products  of  the 
hospital  shops  are  sold  in  the  open  market.  When 
this  last  is  done  there  is  great  danger  of  losing  sight  of 
the  therapeutic  value  of  occupation. 

Besides  the  work  in  shops,  laundry,  farm,  etc.,  it  is 
well  to  have  facilities  for  occupation  on  the  wards. 
Dr.  Horace  G.  Ripley,1  who  is  Director  of  Occupation 
at  the  Taunton  State  Hospital,  is  of  the  opinion  that 
men  patients  should  work  in  shops  and  women  patients 
on  the  ward,  because  normally  a  man  goes  to  his  work 
away  from  his  home,  while  a  woman  does  her  work  in  the 
home.  This  view  would  appear  to  be  a  very  rational 
one  and  seems  to  be  held  by  many  others  in  charge  of 
occupation.  In  visiting  the  state  hospitals  of  New 
England  one  frequently  finds  looms  in  operation  on 
the  women's  wards.  Dr.  Mary  Lawson  Neff,2  who 
has  done  so  much  to  develop  occupation,  has  given  a 
model  program  for  ward  occupation,  as  follows: 
Monday  morning:  The  Housekeeping  Scouts. 

The  cleaning  hour  on  Monday  morning  may  be  made 
to  include  some  element  of  competition.  Prizes  for 
individual  neatness  may  be  offered,  such  as  a  beautiful 
picture  to  hang  each  week  in  the  room  of  the  patient 
who  has  the  best  record  for  the  preceding  week.  The 
members  of  the  ward  family  may  be  divided  into  two 
rival  companies  of  " housekeeping  scouts,"  each  with 
a  leader,  and  some  reward  or  recognition  made  an  object 
of  competition. 

Monday  afternoon:  Phonograph  Concert. 
Tuesday  morning:  Library  Hour. 

The  library  hour  on  Tuesday  morning  should  be  used 

1  Ripley,  Horace  G.,  M.  D.     Should  Occupation  be  Limited  to 
Work   Rooms,  or  Distributed  About  the  Wards?     Transactions 
of  American  Medico-Psychological  Association,  Vol.  xxii,  p.  335. 

2  Neff,  Mary  Lawson.     A  Model  Program  for  a  Ward  in  a  State 
Hospital.    Bulletin  of  Iowa  State  Institutions,  July,  1914, 


THE    DUTIES    OF   THE    OCCUPATION    DIRECTOR  63 

to  increase  to  the  utmost  the  real  value  of  the  library 
and  the  supply  of  other  reading  matter  to  the  hospital. 
Tuesday  afternoon:  Home  Talent  Entertainment. 

Home    talent    programs    should    include     dialogues, 
pantomime,  fancy  dancing,  debates,  etc. 
Wednesday  morning:  Making  Christmas  gifts  and  decora- 
tions or  preparing  for  the  next  holiday. 
Wednesday  afternoon:  Arts  and  Crafts  Class. 

The  arts  and  crafts  class  should  be  taught  by  some 
one  with  the  right  temperament — a  knowledge  of  tech- 
nic  even  is  not  essential. 
Thursday  morning:  Mending  Frolic. 

Thursday  morning  is  to  be  devoted  to  mending.     It 
is  not  easy  to  cast  a  glamor  over  darning  stockings, 
unless  one  has  the  genius  of  a  "  Pollyanna,';  but  something 
else  can  be  done. 
Thursday  afternoon:  Card  Party. 

The  card  party  on  Thursday  afternoon  must  be  made 
a  real  social  event,  not  a  perfunctory,  arranged-by-chance 
group  of  hap-hazard  guests. 
Friday  morning:  Meeting  of  the  Vanity  Club. 

The  vanity  club  of  Friday  morning  indicates  a  time 
definitely  devoted  to  encouraging  the  patients  to  improve 
their  personal  appearance.     It   is  appropriate   on  the 
morning  preceding  the  weekly  dance. 
Friday  afternoon:  The  Helping  Hand. 

"  The  Helping  Hand  "  is  a  club  devoted  to  some  genuine 
form  of  social  service.1 
Saturday  morning:  A  Visit  to  the  Greenhouse. 

The  greenhouse  hour  on  Saturday  morning  develops 
the  aesthetic  faculties,  and  may  stimulate  the  formation  of 
a  class  in  botany  or  for  nature  study,  or  there  may  spring 
from  it  a  gardening  club  for  the  next  spring. 
Saturday  afternoon:  Play  Program. 

The  play  program  on  Saturday  afternoon  offers  an 

1  See  also  Dr.  Leigh  F.  Robinson,  Diversional  Therapy  in  Mental 
Disease.  A  plan  for  its  employment  with  special  reference  to 
social  clubs.  Medical  Record,  vol.  90,  p.  1028,  December  9,  1916. 


64  RECONSTRUCTION    THERAPY 

unlimited  field.     Variety  and  surprise  should  be  provided. 
New  plays  should  be  invented  or  introduced. 
Sunday:  Various  Activities  of  the  Sunshine  Society. 

Sunday  is  not  usually  suitable  for  group  work  but  is 
apt  to  be  somewhat  lonely  and  tedious  for  many  patients. 
The  "Sunshine  Club"  in  one  hospital  supplied  individual 
members  to  cheer  up  a  lonely  newcomer,  to  read  aloud  to 
a  blind  old  lady,  to  give  an  English  lesson  to  a  foreigner, 
to  write  a  letter  for  an  illiterate  girl,  and  to  meet  a  wide 
variety  of  personal  needs  of  this  kind.  A  committee 
also  saw  to  the  care  of  flowers,  the  exchanging  of  maga- 
zines and  the  forwarding  of  Sunday  papers  as  fast  as  read. 
A  few  demented  patients  who  cared  only  for  the  funny 
pages  were  made  happy  by  receiving  them  regularly 
and  promptly. 

It  will  be  noted  that  this  program  aims  to  give  variety 
and  yet  may  be  said  to  be  arranged  somewhat  as  the 
housewife  arranges  her  work  into  regular  duties. 

While  many  simple  crafts  can  be  carried  on  in  ward 
sitting  rooms,  many  others  such  as  metal  work,  book- 
binding, wood  work,  etc.,  require  so  much  paraphernalia 
that  they  can  be  more  conveniently  done  in  rooms  or 
shops  set  aside  for  the  purpose.  It  should  be  remem- 
bered that  the  trip  to  the  shop  may  in  itself  be  a  pleasant 
break  from  ward  monotony. 

In  every  kind  of  hospital  it  is  well  to  be  sure  that  at 
least  one  nurse  on  a  ward  has  sufficient  knowledge  of 
needlework  in  its  various  forms  to  be  of  assistance, 
as  it  will  be  found  that  the  majority  of  women  patients 
will  take  up  a  variety  of  this  work.  Often  the  example  of 
others  will  first  arouse  an  interest  in^this  form  of  occupa- 
tion, and  it  has  the  great  advantage  of  being  portable 
so  that  it  may  be  done  on  the  ward,  in  the  room,  or  while 
sitting  out  of  doors. 

INCORPORATED  HOSPITALS 

Incorporated  hospitals  as  a  rule  administer  trust  funds 
and  admit  a  number  of  patients  at  a  rate  below  the  aver- 


THE    DUTIES    OF   THE    OCCUPATION    DIRECTOR          65 

age  cost  of  care.  Their  work  is  extended  by  caring  for 
others  at  cost  or  more,  any  profits  earned  permitting 
the  reception  of  a  larger  number  of  low-rate  patients. 
The  majority  of  the  population  consists  of  persons  be- 
longing to  what  is  known  as  the  middle  class,  who  are 
not  accustomed  to  manual  labor.  A  considerable  per- 
centage consists  of  acute  cases  such  as  delirium,  stupor, 
or  acute  excitement,  whom  it  is  impossible  to  occupy 
in  .any  way.  This  percentage  is  generally  larger  than 
that  found  in  state  hospitals.  It  is,  therefore,  usually 
impossible  to  occupy  patients  with  any  of  the  routine 
housekeeping  tasks  such  as  is  possible  in  the  state  hos-. 
pitals.  Patients  can  occasionally  be  persuaded  to  assist 
in  the  care  of  their  rooms,  to  carry  trays,  or  similar 
light  tasks,  but  if  asked  to  assist  in  the  kitchen,  laundry, 
garden,  or  elsewhere,  they  are  very  apt  to  refuse  and 
say  that  gentlemen  or  ladies  are  not  accustomed  to  do 
such  work.  While  some  few  patients  may  not  belong 
in  either  of  these  two  groups,  the  example  of  the  major- 
ity will  lead  the  few  to  refuse  to  do  useful  work.  The 
superintendent,  or  his  subordinates,  makes  provision  to 
administer  the  various  housekeeping  or  other  departments 
without  aid  from  the  patients,  so  that  their  assistance 
is  not  needed.  It  can  be  easily  understood  that  social 
or  caste  feelings  might  be  outraged  if  certain  patients 
were  asked  to  assist  in  any  housekeeping  work.  Occu- 
pation is,  therefore,  usually  limited  to  those  occupa- 
tions which  were  long  ago  termed  "some  form  of  busy 
idleness."  As  many  of  the  patients  are  men  and  women 
who  have  broken  down  because  of  too  close  applica- 
tion to  business,  or  housekeeping,  or  care  of  a  family, 
it  is  an  excellent  plan  to  develop  the  play-instinct  which 
has  been  too  much  suppressed,  this  frequently  being  re- 
sponsible for  the  breakdown.  Outdoor  games  are  un- 
doubtedly the  best  means  of  doing  this,  affording  as  they 
do  opportunities  for  play,  exercise  and  fresh  air,  but 
every  ward  should  be  supplied  with  cards,  picture  and 
other  puzzles,  and  various  games. 


66  RECONSTRUCTION   THERAPY 

It  is  well  to  have  all  of  the  outdoor  sports  in  the 
charge  of  a  competent  nurse  or  attendant,  as  such  a  one 
being  less  distracted  by  other  duties  can  take  a  more 
enthusiastic  interest  in  them  than  can  a  physician  whose 
medical  duties  will  often  interfere  at  unfortunate  times. 
This  attendant  should  consult  with  the  director  and  really 
occupies  the  position  of  teacher. 

The  library  will  prove  a  most  valuable  adjunct  and 
many  patients  can  be  induced  to  take  up  reading  courses 
in  art,  history,  literature,  etc.,  which  have  a  very  benefi- 
cial effect. 

Whatever  manual  work  is  done  will  be  in  the  form  of 
crafts,  and  according  to  the  size  of  the  hospital,  that  is, 
the  number  of  patients,  it  will  be  possible  to  have  few 
or  many  of  these  crafts.  It  is  better  to  have  a  few  which 
can  be  carried  to  a  high  point  of  excellence  than  to  have 
a  great  many  which  are  done  in  a  slipshod  way  because 
the  teachers  do  not  have  sufficient  skill  to  properly  in- 
struct the  patients.  But  on  the  other  hand  there 
should  not  be  so  few  that  in  order  to  occupy  patients 
they  must  be  driven  to  the  shops  as  to  a  task.  There 
should  be  a  reasonable  number  of  crafts  from  which  to 
select,  for  without  a  slight  degree  of  interest  on  the 
part  of  the  patient  occupation  loses  its  value  and  becomes 
difficult  to  apply.  A  wood  shop  and  a  metal  shop  afford 
so  many  possibilities  for  variety  that  it  would  seem  best 
to  first  establish  these  and  to  install  such  crafts  as  book- 
binding, weaving  and  pottery  after  the  former  have  been 
found  to  be  inadequate  to  provide  occupation  for  an 
increasing  number  of  patients. 

PSYCHIATRIC  CLINIC 

It  will  require  but  a  moment's  thought  to  realize  that 
in  the  psychiatric  clinic  there  is  much  less  opportunity 
for  occupation  therapy  than  in  any  other  hospital, 
due  to  the  acute  character  of  the  cases  admitted  and  the 
short  time  under  care.  That  is,  if  we  limit  our  concep- 
tion of  occupation  therapy  to  craft  work.  If  on  the  other 


THE    DUTIES    OP   THE    OCCUPATION    DIRECTOR          67 

hand  we  believe  it  includes  any  form  of  entertainment, 
we  can  understand  that  it  may  be  most  helpful  in  caring 
for  patients,  especially  if  used  rather  intensively  and  the 
nurses  are  trained  to  apply  it.  In  the  Henry  Phipps 
Psychiatric  Clinic  of  the  Johns  Hopkins  Hospital  in 
Baltimore  the  average  duration  of  residence  of  the  pa- 
tients admitted  is  but  twenty-four  days.  As  a  small  num- 
ber of  the  patients  spend  several  months  under  care  it  can 
be  realized  that  a  comparatively  large  number  are  in  the 
hospital  but  a  very  short  time.  In  this  clinic  intensive 
care  is  given  in  every  way,  including  occupation.  This 
means  that  the  nurses  are  taught  the  principles  of  ergo- 
therapy,  that  a  certain  amount  of  time  is  given  daily  to 
each  patient  by  the  occupation  director  or  other  teacher 
in  order  that  he  may  do  his  work  understandingly, 
that  there  is  provision  for  amusements  of  all  sorts,  in 
short,  that  everything  possible  is  done  to  divert  the 
patient  and  keep  his  mind  from  his  unhappy  ideas.  It 
is  obvious  that  with  so  much  individual  care  required 
it  is  impossible  to  carry  on  any  industries  and  that  they 
are  out  of  place  in  a  clinic.  All  occupations  should  be  of 
such  a  simple  character  that  not  much  time  is  required 
to  learn  them.  After  needlework,  basketry  and  various 
forms  of  paper  work  are  obviously  the  crafts  which  first 
suggest  themselves.  Simple  wood  work,  such  as  fret 
sawing,  and  metal  work,  such  as  punched  brass,  are  also 
suitable. 

GENERAL  HOSPITAL 

I  have  never  heard  of  an  occupation  director  being 
permanently  attached  to  a  general  hospital,  yet  it  is  easily 
seen  how  greatly  such  an  officer  could  contribute  to  the 
welfare  of  the  patients  and  I  believe  that  the  time  is 
not  far  distant  when  one  will  be  on  the  staff  of  our  larger 
general  hospitals.  The  primary  duty  would  be  to  look 
after  the  entertainment  of  the  patients,  to  instruct 
them  in  games  that  they  may  play,  either  directly  or 
through  the  nurses,  who  must  be  instructed  in  this 


68  RECONSTRUCTION    THERAPY 

most  important  part  of  their  duties.  It  will  possibly 
be  the  surgical  side  which  will  require  the  most  attention 
but  the  milder  or  convalescent  medical  cases  will  also 
need  assistance  in  passing  waiting  hours.  It  would 
appear  possible  that  the  director  might  give  valuable 
aid  to  those  crippled  in  some  way  or  other  by  instructing 
them  how  most  easily  to  do  things. 

The  above  was  written  before  Miss  Susan  E.  Tracy 
had  organized  occupation  in  the  Michael  Reese  Hospital 
in  Chicago  during  the  Spring  of  1916.  She  has  detailed 
this  experience  in  the  Maryland  Psychiatric  Quarterly, 
Vol.  vi,  p.  54,  January,  1917.  It  should  also  be  remem- 
bered that  Miss  Tracy  gave  a  course  in  invalid  occupation 
to  the  nurses  of  the  Massachusetts  General  Hospital 
in  the  Spring  of  1911.  Other  general  hospitals  have  since 
given  occupation  courses,  but  I  have  yet  to  learn  that 
any  general  hospital  has  appointed  a  director  who  is 
permanently  in  charge  of  such  work.  (In  February, 
1918,  the  Presbyterian  Hospital  of  Chicago  was  taking 
steps  to  appoint  one.) 


CHAPTER  V 
HELPS 

In  order  that  occupation  may  be  of  value  to  patients 
it  is  essential  that  a  certain  amount  of  variety  and  change 
be  made  from  time  to  time.  To  a  degree  this  is  attained 
by  the  short  working  periods  with  the  change  from  one 
form  of  occupation  to  another,  but  change  and  variety 
are  necessary  in  the  same  occupation  and  the  director 
and  teachers  must  be  constantly  on  the  alert  for  new 
ideas,  patterns,  etc.  These  may  be  obtained  from  many 
different  sources,  undoubtedly  the  most  prolific  being 
the  various  periodicals  which  specialize  or  have  special 
departments  in  needlework  and  other  crafts. 

There  are  quite  a  number  of  periodicals  which  I  have 
found  inspiring  and  it  may  not  be  amiss  if  some  mention 
is  made  of  them. 

Probably  the  most  helpful  has  been  the  Industrial- Arts 
Magazine,  published  in  Milwaukee  by  the  Bruce  Pub- 
lishing Company,  the  subscription  to  which  is  $1.50 
per  year.  It  is  conducted  especially  for  manual  train- 
ing teachers,  treats  a  diversity  of  subjects,  and  the  man- 
ner of  their  presentation  makes  their  adaptation  for  the 
instruction  of  patients  quite  easy. 

The  School  Arts  Magazine,  published  in  Boston  by  the 
Davis  Publishing  Co.,  at  a  cost  of  $2.00  a  year,  as  its 
title  indicates,  is  somewhat  more  special  in  its  scope 
and  is  intended  to  promote  drawing  and  painting  in 
their  simpler  forms.  The  teacher  will  find  much  that  is 
of  help  in  inculcating  a  knowledge  of  form  and  color, 
both  of  which  are  necessary  in  so  many  crafts  and  which 
have  a  refining  influence  on  all  who  acquire  even  a  slight 
knowledge  of  these  subjects. 

69 


70  RECONSTRUCTION   THERAPY 

Something  To  Do,  published  in  Boston  by  the  Bennett 
Publishing  Co.  at  $1.00,  is  more  elementary  in  character 
but  of  more  general  interest.  As  a  rule  the  ideas  which 
may  be  gained  from  it  are  of  especial  value  for  occupying 
demented  or  low-grade  patients,  but  it  is  worth  having. 

The  Craftsman,  formerly  published  in  New  York 
by  the  Craftsman  Company,  and  succeeded  by  The 
Touchstone,  subscription  S3. 00  per  year,  is  of  value 
more  for  the  ideas  it  suggests  than  for  any  directions 
which  it  may  give.  Occasionally,  however,  specific 
articles  appear,  and  it  has  a  strong  influence  in  promoting 
a  knowledge  of  good  taste. 

The  Art  World  is  a  most  interesting  monthly  with 
a  department  devoted  to  Arts,  Crafts  and  the  Home 
which  usually  contains  one  or  more  articles  of  practical 
interest.  It  is  published  in  New  York  at  $4.00  per  year. 

Arts  and  Decoration,  published  in  New  York  by  Adam 
Budge,  subscription  $3.00  per  year,  is  on  a  still  higher 
plane  than  the  above.  It  is  seldom  that  one  gains  a  posi- 
tive suggestion  yet  the  perusal  of  any  number  is  inspir- 
ing and  one  rises  from  it  with  the  determination  to  make 
the  products  of  the  shops  more  like  those  of  the  older 
craftsmen  so  that  they  will  have  an  artistic  as  well  as 
a  practical  value.  (Since  combined  with  the  Art  World.) 

The  above  periodicals  are  those  which  in  our  experience 
have  proved  of  value,  but  there  are  doubtless  others 
which  would  be  of  service  to  those  with  different  tastes, 
for  example,  a  little  English  weekly  called  Hobbies  which 
is  devoted  especially  to  the  interests  of  fret  sawyers, 
while  not  neglecting  other  subjects.  Among  our  patients 
none  was  found  who  was  interested  in  the  rather  elabo- 
rate designs  furnished.  Especially  in  the  womanly 
crafts  of  needlework,  knitting  and  crocheting,  such 
journals  as  The  Modern  Priscilla,  Woman's  Home  Com- 
panion, Ladies'  Home  Journal,  McC all's  Magazine, 
Delineator,  etc.,  are  of  inestimable  value,  but  are  too 
well  known  to  need  more  than  mention  here. 

The  Playground,  published  in  New  York  by  the  Play- 


HELPS  71 

ground  and  Recreation  Association  of  America  .at  a 
subscription  of  $2.00,  is  very  helpful  in  suggesting 
new  forms  of  amusements  and  stimulating  the  director 
to  keep  active  the  too  often  neglected  play  function. 

Even  advertisements  may  suggest  the  making  of  the 
same  or  somewhat  similar  articles,  but  ideas  will  not  be 
derived  from  books  or  periodicals  alone.  Shop  win- 
dows, museums,  the  homes  of  our  friends,  will  fre- 
quently suggest  ideas  to  be  carried  out  in  the  various 
handicraft  classes.  Frequently  while  going  through  the 
wards  an  idea  for  the  making  of  a  new  article,  or  for  the 
improvement  of  an  already  existing  one  will  occur  to 
the  director  or  teacher. 

When  new  ideas  come  it  is  necessary  that  some  note 
be  made  of  them  lest  they  be  forgotten,  and  in  a  short 
time  these  notes  will  accumulate  to  formidable  propor- 
tions, so  that  some  system  of  classifying  is  necessary 
in  order  to  make  reference  to  them  convenient. 

Probably  the  best  method  is  to  have  a  number  of 
folders  such  as  are  used  for  filing  letters,  consisting  of 
pieces  of  heavy  paper  folded  in  half,  on  which  are  written 
the  various  subjects  upon  which  notes  are  kept,  such  as 
Basketry,  Metal  Work,  Paper  Work,  Aprons,  etc.,  and 
in  these  are  placed  the  clippings  and  notes  that  have  been 
accumulated  relative  to  these  subjects.  This  permits 
the  removal  of  single  clippings,  sketches,  etc.,  which  may 
be  given  to  individual  workers  for  their  guidance.  For 
this  reason  alone  this  plan  is  superior  to  that  of  keeping 
clippings  and  notes  in  scrap  books,  and  is  less  bulky.  An 
ideal  way  would  be  to  give  each  note  or  clipping  a  num- 
ber and  have  index  cards.  This  allows  cross  reference 
and  permits  the  easy  finding  of  a  particular  note  which 
may  have  to  be  filed  out  of  place  because  it  is  on  the 
back  of  another.  This  plan,  however,  entails  consider- 
able labor  in  the  filing  and  the  other  works  out  quite 
satisfactorily. 

Besides  the  notes  and  clippings  which  must  be  kept 
for  reference,  there  should  be  a  small  library  or  collection 


72  RECONSTRUCTION    THERAPY 

of  books  on  the  various  crafts.  These  should  be  in 
some  place  where  they  will  be  convenient  to  all  of  the 
teachers,  rather  than  in  the  different  shops  of  the  in- 
stitution, for  it  is  quite  conceivable  that  a  wood  worker 
may  wish  to  combine  a  certain  article  with  reed  or  metal, 
and  by  referring  to  a  book  on  one  of  these  subjects 
and  working  out  the  problem  for  himself  he  will  broaden 
his  conception  of  the  subject  much  more  than  if  he  re- 
ceives specific  directions. 

For  a  number  of  years  the  Maryland  Psychiatric 
Quarterly,  of  which  I  have  the  honor  to  be  one  of  the 
editors,  has  conducted  a  department  of  Occupations 
and  Amusements  which  is  under  my  direct  supervision. 
In  this  and  in  the  body  of  the  magazine  have  appeared 
a  number  of  interesting  and  suggestive  articles,  as  may 
be  seen  by  consulting  the  Bibliography  of  Occupation 
Therapy  and  the  references  in  this  book.  The  Quarterly 
has  been  made  the  official  organ  for  the  National  Society 
for  the  Promotion  of  Occupational  Therapy  and  as 
such  will  contain  more  information  which  will  be  of 
value  to  occupation  teachers. 

This  society  is  quite  young,  having  been  incorporated 
March  17,  1917.  Its  object  is  to  bring  together  all 
interested  in  the  subject  and  to  increase  knowledge 
by  giving  opportunity  for  the  exchange  of  views.  Prac- 
tically anyone  interested  in  occupational  therapy  may 
become  a  member.  The  secretary  is  Mr.  Louis  J.  Haas, 
Bloomingdale  Hospital,  White  Plains,  N.  Y. 

A  further  help  is  a  record  blank  which  should  be  kept 
for  each  patient  treated  in  this  manner.  The  ideal 
blank  has  not  yet  been  devised  and  probably  never  will 
be,  for  every  one  has  some  difference  of  opinion  on  the 
subject.  The  following  has  proved  very  satisfactory 
in  my  service,  but  Dr.  Jones  in  a  nearby  hospital  prefers 
to  have  the  same  sort  of  information  collected  on  a  form 
having  questions.  This  impresses  me  as  not  so  good 
for  a  running  record  though  satisfactory  to  obtain  infor- 
mation at  a  particular  time,  and  so  it  goes. 


HELPS  73 

SHEPPARD    AND    ENOCH  PRATT  HOSPITAL 
HANDICRAFT  RECORD  OF 

In  order  that  the  physician  may  have  knowledge 
of  the  progress  made  by  patients  in  the  various  handi- 
craft classes  it  is  necessary  that  the  teacher  keep  a 
record  of  their  progress,  keeping  account  of  the  various 
forms  of  work  carried  on  and  also  noting  the  following: 

Attention. — Whether  the  patient  shows  an  interest 
in  the  work  and  gives  little  attention  to  anything  else, 
concentrating  well.  Or  whether  he  is  inattentive  and 
easily  distracted  from  his  task.  Whether  he  soon  shows 
fatigue  symptoms,  such  as  restlessness,  sighing,  etc. 

Ability. — Whether  the  patient  seems  to  understand 
what  is  expected  of  him  and  does  his  work  well.  Whether 
he  shows  initiative  by  overcoming  unexpected  difficulties 
or  accidents  without  immediately  calling  upon  the  in- 
structor for  help.  Or  whether  he  constantly  complains 
that  the  work  is  too  difficult,  etc.  It  should  also  be  noted 
if  there  is  any  periodical  variation  in  doing  the  work. 
If  he  is  neat  or  careless,  works  rapidly  or  slowly,  and 
any  other  points  which  may  be  thought  interesting. 


There  are  so  many  books  which  may  prove  of  value 
that  it  is  -impossible  to  list  them  all,  but  those  named 
at  the  last  of  this  book  have  been  found  very  helpful 
to  the  workers  in  our  hospital  and  I  therefore  give  them 
in  order  to  suggest  to  the  new  director  a  nucleus  for  his 
occupation  library. 

As  everybody  knows  who  is  familiar  with  the  books 
on  any  craft,  it  is  usually  impossible  to  say  that  any 
one  book  is  the  best  on  that  subject.  Each  contains 
good  ideas,  and  while  a  special  one  may  appeal  to  us 
for  several  reasons,  we  find  that  helpful  ideas  may  also 
be  gained  from  others. 


CHAPTER  VI 
FINANCIAL 

Economy  in  administering  occupation  is  usually  a  stern 
necessity  in  hospitals  but  even  though  the  appropriation 
for  this  purpose  be  a  large  one,  there  are  many  reasons 
why  one  should  be  careful  of  expenses,  and  perhaps  the 
first  is  the  effect  on  the  nurse.  It  is  an  unfortunate 
fact  that  owing  to  the  freedom  with  which  supplies 
are  issued  in  institutions  and  the  lack  of  knowledge  of 
their  cost,  employees  frequently  show  a  carelessness  in 
the  use  of  articles  which  might  be  avoided  were 
they  better  informed.  It  is  well,  therefore,  in  the  occu- 
pation course  to  instruct  the  pupils  as  to  the  cost  of 
tools  and  materials.  The  material  for  a  reed  or  raffia 
basket  may  cost  but  15  or  20  cents,  yet  when  given  out 
to  a  number  of  patients  the  total  amount  may  be  con- 
siderable. It  is  important,  therefore,  that  those  in  charge 
of  materials  learn  their  value. 

The  same  applies  to  the  patient,  who  should  not  be 
taught  extravagant  habits. 

The  utilization  of  waste  is  also  important  for  the  reason 
that  the  waste  of  one  department  of  the  hospital  may 
supply  a  necessity  for  another.  For  example,  the  dis- 
carded bed  linen,  dresses,  etc.,  from  the  linen  room  will 
supply  rags  for  weaving  rugs  to  be  used  in  the  ward,  and 
the  burlap  wrappings  of  supplies  can  be  used  for  the  same 
purpose.  The  wood  or  whittling  shop  can  usually  ob- 
tain sufficient  material  for  a  part  of  its  activities  from 
the  crates  and  boxes  discarded  by  the  store  keeper. 

An  important  question  in  the  economical  administra- 
tion of  the  occupation  department  is  the  proper  disposal 
of  the  articles  made  by  the  patients,  which  they  do  not 

74 


FINANCIAL  75 

desire  to  keep.  In  most  hospitals  patients  are  permitted 
to  keep  an  article  which  they  have  made  provided  they 
pay  for  the  cost  of  the  material  used.  This  is  a  fair  rule 
which  has  worked  out  very  satisfactorily. 

Many  hospitals  have  a  case  near  the  administration 
entrance  in  which  are  shown  articles  for  sale,  but  it  is 
doubtful  if  the  revenue  derived  in  this  manner  amounts 
to  more  than  a  trifle,  and  the  advertisement  of  the  fact 
that  excellent  articles  are  made  by  patients  and  that  this 
form  of  therapy  is  used  is  probably  of  much  greater 
value. 

Many  hospitals  also  hold  bazaars  or  fairs  annually 
or  semi-annually  which  are  usually  successful,  and  this 
is  probably  the  best  method  of  disposition  of  the  products 
of  the  occupation  classes.  Many  persons  will  attend 
these  occasions  with  a  charitable  inclination  and,  if 
the  fairs  are  held  before  the  Christmas  season,  others 
find  an  abundance  of  the  articles  which  they  desire  to 
bestow  on  their  friends,  which  may  be  purchased  at  mod- 
erate prices. 

This  question  of  price  is  a  perplexing  one.  As  a  rule 
things  made  by  patients  are  not  so  well  done  as  those 
purchased  in  the  open  market,  hence  they  should  sell 
at  a  lower  price.  Labor  not  being  a  cost  factor  it  is 
possible  to  sell  the  article  at  a  considerable  reduction 
from  the  market  price  and  yet  make  a  profit.  If  a  well- 
finished  article  be  made  and  sold  at  a  low  price  in  compe- 
tition with  the  same  sold  in  the  open  market  there  is 
danger  of  arousing  the  antagonism  of  the  trade  unions, 
who  have  been  known  to  invoke  legislative  action  to 
stop  hospitals  from  offering  any  manufactured  article 
for  sale.  It  is,  therefore,  a  good  rule  to  make  only  enough 
of  articles  that  are  made  by  trades,  for  example  brushes, 
shoes,  etc.,  which  can  be  used  in  the  hospital  or  others 
allied  to  it,  and  to  specialize  in  the  articles  offered  for  sale. 
This  can  easily  be  done  as  there  is,  especially  at  present, 
a  demand  for  hand-made  articles  in  the  various  crafts. 
Some  hospitals  have  a  very  small  appropriation  for  oc- 


76  RECONSTRUCTION    THERAPY 

cupation,  or  perhaps  none,  and  all  the  expenses  of  this 
department  must  be  paid  from  its  earnings,  with  some- 
times the  additional  expense  of  amusement  added. 
While  this  increases  the  difficulty  of  the  problem  it  has 
been  found  possible  in  a  number  of  such  instances  to 
adequately  meet  the  demands.  It  is  naturally  a  source 
of  gratification  to  all  that  the  work  of  the  occupation 
classes  in  at  least  one  institution  is  self  supporting  and 
also  provides  entertainment  for  the  entire  hospital. 

Besides  making  articles  to  be  sold  at  the  annual  bazaars 
and  those  which  are  used,  it  is  a  good  plan  to  do  as  much 
repair  work  as  possible.  In  the  first  place  the  patient 
learns  how  to  repair  articles  in  every-day  use  and  if  he 
returns  to  extra-mural  life  he  is  able  to  diminish  his 
own  or  his  employer's  living  expenses.  Secondly,  the 
principle  of  conservation  is  learned  by  all.  Third, 
there  is  a  diminution  of  the  hospital  expenses.  Fourth, 
by  this  means  it  is  possible  to  keep  the  hospital  equip- 
ment in  good  condition,  and,  fifth,  an  unanswerable  argu- 
ment is  made  against  any  skepticism  as  to  the  value  of 
the  shop.  Any  one  of  the  above  would  appear  to  be  a 
sufficient  reason  why  repair  work  should  be  carried  on, 
but  others  are  not  difficult  to  give. 

It  is  well  to  keep  some  account  of  all  repair  work  done 
and  all  articles  supplied  for  hospital  use,  in  order  that 
proper  financial  credit  may  be  given. 

During  November,  1916,  the  Maryland  State  Hospitals 
held  a  State  Hospitals  Exhibit  and  Sale  which  was  so 
successful  that  plans  were  made  to  open  a  permanent 
salesroom.  It  was  claimed  that  this  was  the  first  sale 
of  this  kind  ever  held.  Some  such  arrangement  might 
be  made  by  other  state  hospital  systems,  or  a  certain 
shop  in  a  town  might  be  induced  to  handle  the  products 
of  the  shops  of  a  nearby  hospital.  Allowance  of  about 
25  per  cent,  for  selling  cost  must  be  made  in  pricing 
articles  which  are  to  be  sold  in  this  way. 

The  following  was  written  by  Reil  in  1803  and  should 
be  kept  in  mind  as  a  guiding  principle.  "The  narrow- 


FINANCIAL  77 

hearted  financier  must  not  follow  us  into  the  mad-house 
to  look  with  wet  eyes  at  every  tuft  of  wool  which  the  in- 
sane man  spoils,  or  even  perhaps  measure  the  increased 
revenue  from  the  institution  with  its  progress.  Insane 
asylums  are  not  intended  for  monetary  profit." 


CHAPTER  VII 
TRAINING  COURSES 

As  has  been  said,  it  is  necessary  that  there  be  hearty 
co-operation  between  the  director  and  the  superintendent 
of  nurses  in  order  that  the  nurses  receive  proper  instruc- 
tion in  occupation.  Within  a  very  few  years  only  has 
this  important  subject  occupied  a  place  in  the  curriculum 
of  both  mental  and  general  hospitals,  and  it  cannot  as  yet 
be  said  to  have  been  accorded  the  recognition  it  deserves. 
Personally  I  believe  that  the  essential  elements  of  occu- 
pation should  be  taught  to  the  probationer  in  order  that 
she  may  early  in  her  work  look  upon  her  patients  as 
people  with  an  illness  rather  than  as  "cases"  of  various 
sorts.  This  would  give  her  an  early  opportunity  to 
acquire  what  Dr.  Stedman1  has  so  happily  termed  the 
"art  of  companionship."  In  the  past,  so  far  as  the 
general  nurse  is  concerned,  this  has  been  left  to  her  own 
initiative  to  develop  and  occasionally  she  has  drifted 
into  the  bad  habit  of  discussing  with  her  patient  details 
of  her  previous  professional  experience  which  may  easily 
have  a  bad  effect.  This  is  due,  I  believe,  to  failure  to 
recognize  the  fact  that  when  a  nurse  leaves  the  full, 
busy  life  of  a  ward  for  that  of  special  or  private  duty, 
she  will  have  during  her  patient's  convalescence  much 
time  which  she  has  not  been  taught  to  occupy  either  to 
her  own  or  the  patient's  advantage. 

For  several  years  there  has  been  a  growing  tendency  to 
give  the  sick  intensive  care,  with ~  the  consequent^em- 
ployment  of  a  greater  number  of  nurses.  This  has  re- 

1  Stedman,  Henry  R.  The  Art  of  Companionship  in  Mental 
Nursing.  Boston  Medical  and  Surgical  Journal,  Vol.  clxx,  p.  673, 
April  30,  1914. 

78 


TRAINING    COURSES  79 

suited  in  the  use  of  many  more  special  nurses.  As  a 
consequence  the  need  of  companionable  women  is  much 
greater  than  formerly,  and  it  would  seem  only  fair  to 
our  pupil  nurses  that  they  be  given  some  slight  instruc- 
tion in  the  art  of  companionship. 

One  great  handicap  is  the  necessity  of  teaching  the 
nurse  so  much  in  a  comparatively  short  time,  but  four 
hours  is  not  too  much  for  instruction  in  the  elements 
of  invalid  occupation  to  the  probationer,  reserving  the 
major  part  of  this  important  subject  until  later  in  the 
training  period. 

Because  registration  in  most  states  is  impossible  for 
the  graduate  nurses  without  a  general  training  the 
majority  of  training  schools  in  mental  hospitals  take  up 
a  good  deal  of  time  in  teaching  the  pupil  nurse  general 
studies  not  necessary  in  her  mental  work,  the  practical 
part  of  her  general  training  being  obtained  after  her 
mental  course  in  some  affiliated  general  hospital.  It  is 
obvious  that  with  such  an  arrangement  the  mental 
hospital  does  not  get  as  full  service  nor  give  as  full  in- 
struction in  its  own  specialty  were  the  nurses'  time  not 
taken  up  with  studies  which  are  not  directly  required 
for  mental  nursing.  Practically  all  nurses  who  have 
received  mental  training  before  their  general  are  of  the 
opinion  that  the  tact  and  ability  to  handle  people  which 
they  have  learned  in  the  mental  hospital  are  of  great  serv- 
ice in  their  general  work.  This  opinion  has  received 
a  strong'endorsement  from  Dr.  G.  Alder  Blumer,  Super- 
intendent of  Butler  Hospital,  who  in  his  annual  report 
of  the  work  of  the  hospital  in  1915  says:  "It  is 
apparent  that  the  feeling  grows  apace  among  candidates 
for  the  profession  that  there  is  a  distinct  advantage  in 
getting  one's  first  lessons  in  a  mental  hospital.  For  here 
is  learned,  better,  I  believe,  than  in  any  other  kind  of 
special  institution,  the  necessity  for  patience  and  self- 
control;  and  the  person  thus  tested  in  the  school  of  ex- 
perience acquires  in  moral  resistance  a  stock  of  ethical 
qualities  that  materialize  themselves  as  character,  to 


80  RECONSTRUCTION    THERAPY 

say  nothing  of  capitalizing  themselves  as  assets  when- 
ever and  wherever  their  fortunate  possessors  proffer 
themselves  as  graduates  in  the  broad  field  of  service." 

On  the  other  hand,  Professor  M.  Adelaide  Nutting, 
Director  of  the  Department  of  Nursing  and  Health  of 
Columbia  University,  says:  "This  important  branch  of 
special  nursing  should  not  be  left  out  of  consideration 
to  be  handled  entirely  independently  of  the  general 
scheme  of  education  for  nurses.  For  such  special  train- 
ing should  at  all  times  rest  upon  a  basis  of  general  train- 
ing. It  should  be  placed  at  a  stage  in  the  education  of 
the  nurse  when  she  is  well  grounded  in  her  preliminary 
sciences,  and  has  sufficient  command  of  nursing  principles 
and  methods  to  be  able  to  apply  them  under  new  and 
peculiar  conditions.  For  it  must  constantly  be  kept  in 
mind  that  many  mental  troubles  are  based  upon  phys- 
ical disorders,  not  infrequently  of  a  grave  nature;  that 
many  mental  troubles  are  constantly  accompanied  by 
bodily  ailments  and  weaknesses.  Every  resource  which 
the  student-nurse  has  learned  to  apply  in  her  medical  and 
surgical  nursing  may  be  called  into  requisition  here.  The 
student,  therefore,  should  have  had  a  considerable 
training  in  general  nursing  before  proceeding  to  this  spe- 
cial branch,  more  difficult,  more  complex,  baffling  often 
even  the  most  intelligent  efforts  and  study  and  making 
in  all  instances  a  new  and  special  demand  upon  faculties 
trained  to  comprehend  in  some  degree  the  nature  of  these 
demands." 

Theoretically  I  agree  with  Miss  Nutting  that  the  gen- 
eral training  should  by  all  means  precede  the  special  or 
mental  training,  but  practically  it  has  been  found  that 
nurses  who  have  had  general  training  before  their  mental 
are  prone  to  be  so  engrossed  with  the  observation  of 
objective  symptoms  that  they  become  oblivious  to  the 
subjective.  In  summing  up  the  matter  it  may  be  said 
that  we  will  have  good  nurses  and  poor  nurses  no  matter 
what  training  is  given,  and  a  good  mental  nurse  will  not 
necessarily  be  a  good  general  nurse  even  though  she  has 


TRAINING    COURSES  81 

the  best  training,  and  vice  versa.  A  short  course  in  occu- 
pation has  seemed  to  me  to  be  an  excellent  method  of 
teaching  certain  psychological  facts  in  a  way  that  will 
make  them  most  obvious  to  the  pupil,  and  enable  her 
to  make  practical  application  of  the  knowledge  of  psy- 
chology which  she  will  acquire  later. 

To  the  training  school  the  director  will  occupy  the 
position  of  instructor  just  as  do  the  physicians  who 
teach  any  other  branch  of  nursing. 

The  character  of  the  course  which  he  gives  will  vary 
according  to  the  class  of  patients  treated  and  to  the 
time  allowed  for  it  so  that  it  is  impossible  to  state 
of  what  it  should  consist.  A  rather  simple  one  which 
has  been  given  under  my  direction  at  the  Sheppard  and 
Enoch  Pratt  Hospital  for  several  years  is  as  follows: 

The  course  comprises  at  least  twelve  lessons,  but  is  not 
considered  complete  until  all  the  pupils  have  done  the 
required  work. 

I.  Games. — Pupils  are  required  to  learn  Crib- 
bage,  Euchre,  Whist  or  Bridge,  and  Fan-Tan; 
three  forms  of  Solitaire,  Baker's  Dozen,  Can- 
field  or  Klondyke,  and  Rainbow;  also  Domi- 
noes, Sniff  and  Checkers. 

They  are  also  given  a  talk  upon  the  use  of 
various  forms  of  puzzles  and  are  given  a  num- 
ber of  simple  puzzles  in  order  to  start  a  col- 
lection. 

II.  String  Work. — After  learning  to  serve,  to  braid 
four  or  more  flat,  and  four  round,  and  to  tie 
square,  crown,  and  wall  knots,  the  nurses  are 
taught  the  application  of  these  in  making 
fobs,  guards  or  other  articles. 

They  also  learn  to  make  a  string  doll  or  a 
duster — these  being  modifications  of  a  tassel — . 
and  to  make  a  doll's  hammock  or  a  bag  upon 
a  pasteboard  base — this  being  an  introduction 
to  weaving. 


82  RECONSTRUCTION    THERAPY 

III.  (a)  Paper   Folding. — The   required   forms  are 
an  envelope,   a  cup,  a  fish's  mouth,  a  frame, 
and  a  box. 

(6)  Paper  Cutting. — A  star,  a  string  of  dolls 
are  the  first  steps,  being  a  combination  with 
folding.  Cut-out  pictures,  usually  of  simple 
form,  are  also  made. 

Besides  the  above  certain  other  forms  are 
suggested  and  shown  but  are  not  required. 

IV.  Binding. — Simple  pamphlet  stitching  is  taught 
and  also  a  combination  of  a  number  of  folded 
sheets  to  form  a  scrap-book. 

V.  Crepe-paper  Work. — Usually  some  simple  ob- 
jects are  made  in  order  to  teach  the  possibilities 
of  crepe-paper  and  crepe-paper  rope. 
VI.  Reed  Basketry. — Each  nurse  makes  a  basket 
and  is  taught  various  combinations  of  weaving 
the  same. 

VII.  Embroidery  and  needlework  are  discussed  in  a 

talk  and  the  value  of  the  various  forms  in 

different  psychoses  is  brought  out  by  examples 

shown. 

VIII.  Leather  Work. — A  demonstration  of  the  technic 

of  carving  and  hammering  leather  is  given. 
IX.  Wood  Work. — This  consists  of  a  demonstration 
of  simple  wood  carving,  and  of  practical  work 
in  the  shop  in  making  simple  objects  such  as 
paper  knives,  canes,  trays,  bird-houses,  wind 
toys,  stools,  etc. 

X.  Metal  Work. — This  consists  of  practical  work  in 
Venetian  iron  work,  hammering  copper,  making 
copper  ornaments,  initials,  paper  cutters,  etc. 

Each  nurse  is  encouraged  to  develop  a 
particular  branch  of  the  work  and  to  become 
especially  proficient  in  it.1 

1  The  above  course  is  frequently  amplified  in  minor  particulars 
such  as  practical  work  being  required  instead  of  a  demonstration 
being  given. 


TRAINING    COURSES  83 

There  is  usually  an  introductory  talk  by  the  director 
during  which  the  principles  of  work  cure  are  emphasized, 
interesting  facts  in  the  history  of  its  development  are 
mentioned  and  the  importance  of  its  use  illustrated 
by  reference  to  specific  cases  who  are  being  aided. 

It  will  be  noted  that  in  the  above  courses  the  idea  is  to 
teach  the  nurse  some  of  the  possibilities  of  the  materials 
which  she  may  have  at  hand,  so  that  she  will  never  be 
at  a  loss  for  something  to  do. 

Those  who  are  familiar  with  Miss  Tracy's1  excellent 
book  will  recall  that  by  its  arrangement  the  nurse  is 
taught  to  consider  the  capabilities  of  her  patient, 
chapters  being  written  for. the  impatient  boy,  grand- 
mother, the  business  man,  etc. 

In  comparing  these  standpoints  it  must  be  remembered 
that  in  the  course  outlined  above  we  are  considering 
but  one  class  of  patients,  the  mentally  sick,  and  the 
nurse  may  very  easily  learn  to  make  further  applications 
of  what  she  has  learned  for  herself  when  necessary. 
While  the  statement  may  at  first  seem  paradoxical, 
the  mentally  sick  in  their  capabilities  for  occupation 
approach  more  nearly  the  normal  than  those  physically 
defective,  such  as  the  blind  or  crippled. 

It  has  been  found  that  the  nurse  who  has  been  con- 
scientious in  her  work  in  the  above  course  has  acquired 
rudiments  which  may  be  quite  easily  developed  by  herself 
and  it  is  believed  that  some  such  course  is  sufficient 
training  in  what  may  be  called  manual  occupations. 
But  there  is  another  very  important  side  to  the  nurse's 
training  in  occupation.  In  the  private  and  incor- 
porated hospitals  the  majority  of  the  patients  belong  to 
what  is  known  as  a  cultivated  class,  that  is,  they  are 
men  and  women  who  have  had  time  to  gain  a  knowl- 
edge of  the  literature  of  their  own  language  and  perhaps 
of  others,  and  have  learned  to  know  something  about 
good  music,  art,  etc.  It  must  be  at  once  admitted  that 

1  Tracy,  Susan  E.  Studies  in  Invalid  Occupation.  Boston, 
1910,  Whitcomb  &  Barrows. 


84  RECONSTRUCTION   THERAPY 

the  majority  of  our  pupil  nurses  are  not  intellectually 
on  the  same  plane  as  their  patients,  because  they  have 
lacked  the  time  and  opportunities,  perhaps,  to  read, 
travel,  or  study  to  the  extent  their  patients  have  enjoyed. 
At  the  same  time  the  nurse  must  be  a  companion  to  her 
patient  and  this  is  not  possible  unless  she  has  broadened 
her  mental  horizon  by  study  of  literature,  art,  and  music. 
In  order  that  this  may  be  accomplished  in  the  shortest 
possible  time  it  is  necessary  to  give  some  of  the  so-called 
culture  courses  similar  to  those  given  at  the  McLean 
Hospital  and  outlined  by  Miss  Edith  Kathleen  Jones,1 
the  librarian,  who  gives  them.  They  are  given  in  the  form 
of  lectures  with  a  certain  amount  of  required  reading, 
and  the  course  on  art  is  well  illustrated .  Naturally 
in  these  courses  it  is  impossible  to  do  more  than  give  the 
most  important  points.  A  literature  primer,  such  as 
Stopford  Brooke's,  may  be  taken  as  an  outline  for  a 
course  in  English  literature,  and  "Apollo"  for  a  course 
in  art,  but  even  these  if  followed  closely  will  give  courses 
which  are  too  long  and  may  have  to  be  abridged.  Miss 
Jones  has  given  a  strong  impetus  to  these  culture  courses 
by  publishing  an  outline  of  a  course  of  lectures  on 
Books  and  Reading.2 

A  trained  librarian  is  naturally  the  person  to  give  these 
but. in  the  absence  of  one  it  may  be  possible  to  get  one 
of  the  assistant  physicians  to  give  up  an  evening  a  week 
to  this  work. 

A  player  piano  or  some  other  form  of  mechanical 
musician  can  be  utilized  to  educate  both  nurses  and 
patients  as  to  what  is  good  music,  and  the  free  use  of  even 
such  cheap  pictures  as  the  Perry  Prints  will  aid  in  cul- 
tivating a  knowledge  of  the  most  famous  paintings. 
Associated  facts  should  be  given  with  these. 

The  nurse  should  be  taught  dancing  and  any  other 

1  Jones,  Edith  Kathleen.  Culture  Course  in  Training  Schools 
for  Nurses.  The  Modern  Hospital,  Vol.  iii,  p.  205,  September, 
1914. 

1  American  Journal  of  Insanity,  Ixxii,  p.  299,  October,  1915. 


TRAINING    COURSES  85 

form  of  physical  exercise  in  which  it  is  necessary  for  her 
to  participate.  Participation,  be  it  remembered,  is  a 
strong  factor  in  making  occupation  effective. 

Especially  in  private  and  incorporated  hospitals  should 
the  nurse's  training  be  developed  toward  making  her  a 
good  companion.  We  do  not  ordinarily  require  that  our 
friends  should  possess  a  knowledge  of  anatomy  and 
bacteriology,  but  we  do  require  that  they  should  have  a 
knowledge  of  some  of  the  same  books,  music,  pictures, 
etc.,  that  we  ourselves  have.  Hence  it  would  seem  but 
logical  that  for  mental  nurses,  at  least,  there  be  some 
modification  in  the  early  course  of  study.  Probably 
the  day  is  not  far  off  when  there  will  be  more  intensive 
training  of  the  nurse  in  the  specialties  and  a  shortening 
of  her  course  in  general  work. 

The  nurse's  occupational  training  is  facilitated  by  the 
use  of  an  accomplishment  card  which  may  be  arranged 
as  follows: 


Name  Class 


Post  Graduate 

Junior 

Senior 

Probationer 

Attendant 

Basketry,  Reed 

Raffia 

Embroider 

Crochet 

Knit 

Net 

Tat 

Fagot 

Featherstitch 

Quilt 

Sew,  Hand 
Machine 

Stencil 

Metal  Work 

Leather  Work 

Wood  Work 

Draw,  Design  or  Paint 


86  RECONSTRUCTION    THERAPY 

Play  What  Musical 

Instrument 
Sing 

What  Voice 
Read  Well 
Or  Recite 
Taken  Part  in 

Theatricals 
Play  Tennis 
Croquet 
Basket  Ball 
Golf 
Or  Other 

Outdoor  Game 
Calisthenics 
Dance 
Swim 
Bowling 

or  in  any  other  convenient  form.  Comment  on  their 
value  seems  superfluous,  but  Miss  Cameron  has  said:1 

"Most  Industrial  Workers,  whether  they  belong  to  the 
nursing  staff  or  not,  will  agree  with  me  when  I  say  that 
co-operation  on  the  part  of  the  nurse  is  most  important 
in  the  occupational  department  of  each  hospital,  as 
occupation  has  proved  to  be  a  most  powerful  therapeutic 
agent  in  the  treatment  and  cure  of  nervous  and  mental 
diseases.  We,  who  are  superintendents,  are  very  careful 
to  find  out  certain  qualifications  the  prospective  pupil 
possesses  before  we  admit  her  as  a  part  of  the  training 
school,  but  the  occupational  qualifications  we  have  in 
the  past  overlooked.  Providing  the  probationer  is  the 
right  age,  is  of  proper  height,  and  has  the  required  educa- 
tional and  moral  qualifications,  the  average  superintend- 
ent does  not  inquire  whether  the  prospective  pupil 
can  knit,  sew,  do  basketry,  sing,  dance  or  play  cards. 

"The  time  is  here  when  we  should  consider  the  occupa- 
tional qualifications  of  the  nurse  as  well  as  the  others, 

1  Cameron,  Reba  G.  The  Value  of  the  Accomplishment  Card 
(Editorial).  Maryland  Psychiatric  Quarterly,  Vol.  iv,  p.  55, 
January,  1915. 


TRAINING    COURSES  87 

and  by  so  doing  aid  the  occupational  teachers  in  their 
work,  and  increase  the  efficiency  of  the  nursing  staff, 
for  nowadays  a  nurse  who  is  versed  in  occupational  work 
is,  without  a  doubt,  of  more  value  than  one  who  knows 
absolutely  nothing  of  industries. 

"In  order  to  find  out  what  lines  of  work  the  nurse  may 
already  possess,  an  accomplishment  card  might  be  given 
to  each  nurse  on  admission  with  instructions  to  fill  in  and 
hand  to  the  Superintendent  of  Nurses  before  a  stated 
time.  The  card,  as  outlined,  is  excellent,  and  when  these 
are  handed  in  the  Physicians,  the  Superintendent  of 
Nurses,  and  the  Industrial  Workers  will  know  at  a  glance 
that  Miss  Jones  can  knit  and  do  plain  sewing;  Miss  Brown 
plays  the  piano,  and  Miss  Smith  understands  raffia  work. 

"Now,  of  what  advantage  is  this  knowledge  to  us  when 
we  have  found  it  out  ?  Let  me  illustrate,  using  the  pres- 
ent war  as  an  example.  A  number  of  hospitals  are 
doing  relief  work,  and  the  question  comes  up,  'Who 
understands  knitting?'  Instead  of  asking  each  one 
individually  whether  or  not  she  can  knit,  we  consult 
our  information  cards  to  find  out  that  Misses  Jones, 
Brown  and  Smith  know  how  to  knit,  so  these  nurses 
can  be  assigned  classes  in  this  old-fashioned  but  useful 
art  which  has  revived  considerably  since  the  present 
war  broke  out. 

"Again,  the  industrial  teacher  may  arrange  some  little 
entertainment  for  an  evening's  enjoyment,  and  by  con- 
sulting the  cards  can  find  who  can  recite,  sing  and  do 
fancy  dances,  and  all  needless  questioning  is  avoided. 

"One  more  illustration  to  show  the  advantage  of  the 
accomplishment  card  to  individual  patients.  Mr.  Jones, 
an  artist,  is  admitted  in  a  much  depressed  condition. 
It  is  very  difficult  to  interest  this  patient  in  the  industrial 
pursuits  on  his  ward.  Caning  chairs,  basketry,  or  weav- 
ing does  not  appeal  to  him,  and  the  industrial  instructors 
in  a  large  institution  cannot  spend  very  much  time  with 
individual  patients,  so  we  consult  our  cards  and  we 
find  that  Miss  A.,  knows  something  of  drawing  and  paint- 


88  RECONSTRUCTION   THERAPY 

ing,  thus  Miss  A's  services  are  brought  into  play.  She  is 
placed  on  this  ward  as  nurse  and  given  instructions  to 
interest  herself  in  this  patient.  Before  long  we  find 
Mr.  Jones  helping  Miss  A.,  illuminating  Christmas 
cards  and  calendars.  Interest  takes  the  place  of  apathy 
and  his  fancied  grievances  are  on  a  fair  way  to  be 
forgotten. 

"I  would  add  in  closing  that  this  card  system,  as  out- 
lined, is  well  worth  trying  and  superintendents  who  in- 
troduce it  in  the  Training  School  will  do  so  to  their  own 
advantage  as  well  as  to  the  advantage  of  the  patients 
and  to  the  occupational  department  of  the  Hospital." 

The  course  which  has  been  outlined  is  an  extremely 
simple  one  and  represents  the  minimum  probably,  of 
what  should  be  given.  Experience  will  perhaps  do  more 
to  assist  the  director  in  formulating  one  suitable  for 
local  conditions  than  will  a  number  of  outlines.  The 
primary  object  of  all  courses  should  be  to  develop  the 
initiative  of  the  nurse  so  that  she  can  make  the  best 
possible  use  of  her  knowledge. 

During  1917  I  wrote  a  paper,1  introducing  several 
other  papers  upon  the  training  of  occupational  teachers 
and  directors,  and  in  this  gave  outlines  of  several  differ- 
ent courses.  While  these  are  perhaps  too  full  for  use 
in  the  training  school  they  are  suggestive.  Reference 
may  also  be  made  to  the  following: 

Reba  G.  Cameron.  The  Training  of  Occupation 
Teachers.  Maryland  Psychiatric  Quarterly,  Vol.  vii,  p. 
33,  October,  1917;  Evelyn  L.  Collins.  Suggested  Course 
in  Occupation  Therapy.  Ibid.,  p.  36;  Isabelle  Roorbach, 
Course  in  Invalid  Occupation.  Ibid.,  p.  39;  see  also 
those  given  in  the  Chapter  on  Occupational  Therapy  and 
the  War. 

1  The  Training  of  Occupational  Teachers  and  Directors.  Mary- 
land Psychiatric  Quarterly,  Vol.  vii,  p.  8,  July,  1917. 


CHAPTER  VIII 
AMUSEMENTS 

At  the  present  time  there  is  no  hospital  which  to  my 
knowledge  utilizes  amusements  to  the  extent  that  is 
possible  for  the  benefit  of  the  patients.  With  but  slightly 
more  effort  the  various  forms  can  be  made  to  do  more 
than  merely  divert  for  the  time  that  they  are  in  progress. 
Practically  all  forms  of  amusement  if  properly  used  can 
be  made  to  serve  as  means  of  re-education.  The  simple 
forms  of  amusement  which  are  found  upon  the  wards 
and  which  are  usually  used  for  the  diversion  of  single 
patients,  such  as  picture  puzzles  and  games  of  solitaire 
can  be  well  used  to  train  attention.  They  may  also  be 
used  for  muscle  training.  The  nurse  may  be  obliged 
to  assist  in  these  in  order  to  stimulate  the  patient  and 
get  him  started,  but  usually  this  is  only  necessary  for  a 
short  period,  and  if  tactfully  done  the  patient  may  be 
encouraged  to  do  a  great  deal  without  assistance.  So 
too,  when  convalescent  the  patient  may  take  part  in 
double  or  four-handed  games  where  a  greater  amount  of 
concentration  is  necessary  and  where  a  tendency  to  irri- 
tability must  be  inhibited. 

Reading,  primarily  taken  up  for  diversion,  may  become 
a  means  of  culture  and  self-education.  We  all  know  the 
satisfaction  which  follows  the  reading  of  a  book  which 
serves  to  increase  our  knowledge  and  there  is  a  great  deal 
of  fiction  which  gives  historical,  or  other  facts,  in  a  sugar- 
coated  form.  For  example,  Mark  Twain's  The  Prince 
and*the  Pauper,  or  Charles  Major's  When  Knighthood 
wasjin  Flower  may  serve  as  a  stimulus  for  collateral 
reading  to  determine  the  historical  accuracy  of  these 
works.  Much  can  be  accomplished  by  the  collation 


90  RECONSTRUCTION    THERAPY 

of  related  facts  and  patients  can  be  stimulated  and  shown 
how  to  gather  these  facts  for  themselves.1  I  know  of 
one  young  woman  who  was  started  upon  a  study  of  moths 
by  reading  Gene  Stratton  Porter's  books. 

With  the  congregate  amusements  where  large  groups 
of  patients  are  to  be  entertained  it  is  sometimes  difficult 
to  do  much  more  than  divert,  but  let  us  consider  a  few 
of  these  in  detail. 

MOVING  PICTURES 

Moving  pictures  are  very  popular  as  an  amusement  at 
the  present  time,  their  convenience  and  comparative 
cheapness  being  to  quite  a  degree  responsible.  Unfor- 
tunately the  film  makers  have  not  as  yet  learned  "what 
the  public  wants"  and  as  a  consequence  are  making  reels 
which  are  melodramatic,  filled  with  unhealthy  sentiment, 
or  even  shocking.  In  mental  hospitals  we  count  our- 
selves fortunate  if  the  movie  evening  passes  without 
having  suggested  suicide,  or  death  in  some  other  form, 
something  unpleasant  or  worse.  If  anyone  doubts  that 
moving  pictures  stir  up  the  emotions  let  him  go  to  any 
movie  parlor  and  observe  how  many  persons  wipe  their 
eyes  during  the  passage  of  certain  films.  If  he  thinks 
this  is  due  to  the  bright  light  let  him  observe  if  the  same 
effect  results  during  the  passage  of  a  humorous  film. 
Selecting  reels  is  difficult  for  anyone  not  connected  with 
a  film  exchange  and  it  is  best  to  enlist  the  co-opera- 
tion of  the  man  from  whom  they  are  rented  and  ex- 
plain to  him  the  character  of  reels  desired.  The  very 
humorous,  even  farcical  subjects,  are  of  value  in  that 
they  frequently  force  a  laugh  and  self-forgetfulness  by 
their  absurdity.  So-called  educational  films,  such  as 
scenes  of  foreign  countries,  are  not  especially  divert- 
ing unless  there  is  some  accompanying  description  or 
unless  comment  is  made  by  a  lecturer.  Patients  are 
always  interested  in  scenes  of  activity  such  as  films 

1  Geo.  Edward  Barton.  Inoculation  of  the  Bacillus  of  Work. 
Modern  Hospital,  Vol.  viii,  p.  399,  June,  1917. 


AMUSEMENTS  91 

which  begin  with  the  harvesting  of  wheat  and  end  with 
the  delivery  of  a  loaf  of  bread,  or  scenes  in  some  large 
manufacturing  plant,  or  at  a  shipbuilding  yard.  There 
are  plenty  of  films  in  which  a  good  story  is  told  and 
frequently  historical  events  are  dressed  up  with  some 
romance  which  adds  rather  than  detracts  from  them. 
The  groups  which  have  been  named  above  all  have  value 
in  stimulating  the  interest  of  patients  in  affairs  outside 
of  themselves.  Some  believe  that  films  which  tell  their 
story  in  one  reel  are  best  and  those  requiring  more  than 
five  should  be  tabooed,  but  experiment  should  prove 
or  disprove  this. 

A  song  or  short  instrumental  piece  between  reels 
adds  considerably  to  the  pleasure  of  the  entertainment. 
At  one  that  I  attended  held  near  the  anniversary  of  the 
death  of  Stephen  G.  Foster  one  of  the  assistant  physicians 
read  a  brief  sketch  of  Foster's  life  and  in  subsequent 
intermissions  sang  some  of  his  songs.  This  sort  of  thing 
might  easily  be  developed,  but  without  too  much  em- 
phasis being  laid  on  the  death  of  the  subject. 

DRAMATICS 

Probably  no  form  of  entertainment  is  more  enjoyed 
by  hospital  patients  than  the  "home  grown"  play  in 
which  the  patient  sees  some  favorite  nurse  perform  in 
a  costume  or  with  properties  that  the  patient  has  per- 
haps helped  to  make.  These  may  consist  of  some  stand- 
ard play  like  Box  and  Cox  or  the  more  simply  gotten 
up-  vaudeville.  It  is  an  excellent  plan  to  organize  a 
stock  company  to  take  charge  of  this  work  and  give  a 
number  of  entertainments  during  the  winter,  different 
groups  giving  different  plays.  It  is  necessary  for  the 
director  to  have  an  assistant  to  serve  as  stage  manager, 
who  will  take  charge  of  a  great  deal  of  the  detail  in 
connection  with  entertainments.  A  nurse  or  attendant 
whose  regular  work  can  be  dropped  for  short  periods  and 
who  has  a  liking  for  dramatics  will  probably  prove  the 
best  assistant.  This  stage  manager  can  look  after  the 


92  RECONSTRUCTION   THERAPY 

properties  and  costumes  which  necessarily  accumulate  in 
a  hospital,  and  keep  them  from  being  lost  or  destroyed, 
and  also  aid  in  prompting,  dressing,  etc.,  at  a  performance. 
Such  an  assistant  is  necessary  even  though  the  director 
himself  gives  up  a  good  deal  of  time  to  getting  up  the  play. 

It  is  questionable  whether  patients  should  be  allowed 
to  take  part  in  these  entertainments.  I  believe  that 
learning  and  rehearsing  a  play  is  ordinarily  too  much 
of  a  tax  upon  convalescents  but  that  they  frequently 
can  be  allowed  to  do  a  "stunt"  at  a  vaudeville.  In 
this  way  there  need  be  no  interference  with  the  perform- 
ance if  the  patient  feels  unequal  to  "going  on,"  and  as 
he  is  not  an  essential  part  in  it  he  is  not  so  apt  to  become 
nervous  and  apprehensive. 

There  is  no  question,  however,  that  the  preparation  of 
a  play  can  be  so  managed  as  to  be  helpful  in  developing 
an  esprit  de  corps  and  of  loyalty  to  the  hospital  among 
the  participants.  This  is  especially  the  case  when  groups 
of  nurses  and  other  employees  are  brought  ^together  for 
this  purpose.  Elsewhere1  I  have  told  how  the  exchange 
of  home  shows  between  different  hospitals  has  worked 
satisfactorily. 

ORCHESTRA 

The  same  spirit  of  loyalty  may  be  developed  by  the 
organization  of  an  orchestra  which  can  play  at  dances, 
give  concerts,  and  otherwise  add  to  the  enjoyment  of 
all.  It  is  usually  impossible  to  form  an  orchestra  ex- 
cept in  the  larger  hospitals  and  a  competent  leader  is 
always  necessary.  Here  it  is  possible  to  cultivate  a 
taste  for  better  music  and  often  a  few  remarks  upon  the 
composer  and  his  work  which  is  to  be  played  will  se- 
cure a  more  attentive  hearing. 

LECTURES 

Lectures  formerly  were  overdone  and  consisted  of  some 
one  reading  from  a  guide  book  while  lantern  slides  were 

1  Maryland  Psychiatric  Quarterly,  Vol.  ii,  p.  35,  October,  1912. 


AMUSEMENTS  93 

shown.  Naturally  this  was  a  perfunctory  and  unin- 
teresting performance  and  probably  as  a  result  of  this 
but  few  lectures  are  now  given  to  audiences  in  mental 
hospitals.  This  is  to  be  regretted  for  a  certain  number 
in  the  audience  will  always  take  an  especial  interest 
in  the  subject  presented  and  will  therefore  be  benefited. 
It  is  often  possible  to  find  a  person  who  has  delivered 
an  interesting  talk  before  some  club  or  church  who  is 
willing  to  repeat  it  for  the  benefit  of  the  patients.  As 
these  are  frequently  accounts  of  personal  experiences 
they  are  so  much  the  more  interesting. 

Smaller  groups  of  patients  will  be  interested  in  the  lec- 
tures on  art  or  literature  which  are  given  to  the  nurses 
as  culture  courses  and  it  is  possible  to  allow  them  to  share 
in  such  a  course. 

The  various  members  of  the  staff  should  be  encouraged 
to  talk  of  their  different  hobbies,  as  they  can  all  be  made 
interesting. 

OUTDOOR  GAMES 

Baseball  probably  takes  the  lead  as  there  are  very  few 
boys  and  even  girls  born  in  the  United  States  who  have 
not  at  one  time  played  it.  Those  debarred  from  active 
participation  in  the  game  should  be  encouraged  to  become 
rooters  and  so  exercise  their  lungs.  When  bad  weather 
prevents  out-of-door  playing,  it  is  possible  to  have 
enjoyable  and  amusing  games  in  a  gymnasium  or  other 
large  room  by  playing  indoor  baseball  or  some  home-made 
substitute  for  it.  Besides  games  with  outside  teams, 
who  must  necessarily  be  well  behaved,  it  is  well  to  en- 
courage a  rivalry,  where  the  population  permits,  between 
teams  from  different  wards  or  buildings  or  special  teams 
made  up  for  the  purpose  and  having  some  fanciful  name. 

The  enjoyment  of  all  may  be  increased  by  some  ex- 
planation of  the  game  and  the  various  plays  and  names. 
It  is  well  to  take  small  groups  of  patients,  especially  of 
the  women,  and  give  little  explanatory  talks,  illustrated 
on  a  blackboard  or  chart,  so  that  those  unfamiliar  with 


94  RECONSTRUCTION    THERAPY 

the  game  can  understand  what  it  is  all  about  and  eventu- 
ally distinguish  between  a  hit,  error,  assist,  out,  Texas 
Leaguer,  etc.  All  spectators  should  be  encouraged  to 
keep  score  on  cards  which  may  be  prepared  in  the  printing 
shop. 

Cricket  is  also  a  good  game  but  for  many  reasons  can 
never  be  as  popular  as  baseball.  In  the  first  place  it 
lacks  the  variety  and  action  of  the  latter,  and  secondly, 
requires  too  long  to  complete  a  game.  Thirdly,  too  few 
spectators  are  familiar  with  it,  therefore  explanatory 
talks  are  even  more  necessary  than  for  baseball.  As 
exercise  for  the  participants  it  has  the  advantage  over 
baseball,  however,  in  being  less  strenuous. 

Tennis,  golf,  and  croquet  are  all  excellent  and 
facilities  for  playing  should  be  provided.  In  order 
to  keep  up  interest  the  element  of  competition  should  be 
introduced  by  holding  fairly  frequent  tournaments. 
These  should  be  so  arranged  that  those  players  who  are 
most  equally  matched  in  skill  shall  compete  against  each 
other. 

BASKET  BALL 

Basket  ball  is  usually  played  indoors  during  winter 
months,  but  can  also  be  played  outdoors  and  its  action 
makes  it  an  interesting  game  to  watch.  When  played 
by  girls  or  women  certain  changes  are  made  in  the  rules 
so  as  to  eliminate  the  probability  of  roughness.  It  is  well 
to  organize  a  number  of  teams  if  possible  so  that  there 
may  be  the  stimulus  of  competition. 

VOLLEY  BALL  GAMES 

Quite  a  number  of  games  can  be  played  with  a  volley 
ball,  such  as  volley  ball  itself,  which  is  a  modified  form 
of  badminton,  monkey  ball,  playground  ball,  etc. 
These  volley  ball  games  are  much  better  than  base- 
ball for  those  who  are  "soft"  and  whose  muscles  are 
not  hardened  to  the  degree  that  is  necessary  for  so  active 
and  prolonged  a  game  as  baseball.  These  games  may 
also  be  played  indoors  or  out. 


AMUSEMENTS  95 

FIELD  AND  TRACK  ATHLETICS 

An  athletic  meet  is  always  enjoyed  by  those  who  are 
spectators  as  well  as  those  who  compete.  Some  hospitals 
make  the  Fourth  of  July  Games  an  annual  event  but 
it  is  probably  better  to  hold  them  in  the  Spring  or  Fall 
when  the  weather  is  less  trying  to  the  entrants.  The 
training  or  practice  period  for  these  events  is  of  value. 

Besides  the  forms  of  amusements  which  have  been 
mentioned,  there  are  many  others  which  will  suggest 
themselves,  such  as  picnics,  bowling,  card  parties,  candy 
pulls,  etc. 

It  is  often  possible  to  have  parties  on  the  wards  on 
rainy  days,  or  to  celebrate  a  birthday  or  some  other  event 
which  will  be  greatly  enjoyed  by  the  patients  because 
of  the  impromptu  character,  and  especially  if  they  are 
allowed  to  share  in  the  necessary  preparation.  Nurses 
should  be  encouraged  to  have  these  parties  as  they  cre- 
ate an  excellent  spirit  of  friendliness  and  confidence. 

Their  cost  need  be  but  trifling  and  this  is  far  out- 
weighed by  the  good  accomplished.  I  have  often  seen 
a  patient  become  more  co-operative  and  let  down  his 
reserve  because  he  became  appreciative  of  the  friendly 
spirit  which  actuated  a  party.  While  an  impromptu 
affair  is  often  much  enjoyed,  it  is  well  to  announce  such 
events  when  possible  in  order  that  the  pleasure  of  antici- 
pation may  be  enjoyed. 

Interest  in  all  entertainments  such  as  shows,  lectures, 
games,  etc.,  should  be  stimulated  by  the  use  of  posters 
announcing  them.  If  the  hospital  is  small  and  has  no 
printing  shop  these  can  be  lettered  by  hand,  opportunity 
being  afforded  for  any  ornamentation  which  will  catch 
the  eye.  It  has  been  found  when  posters  are  used  that 
much  more  interest  is  taken  in  the  performances.  Pro- 
grams, dance  cards,  or  score  cards  add  much  to  the  en- 
joyment of  a  certain  number  and  undoubtedly  aid  in 
concentrating  their  attention.  Menus  and  decorations 
will  make  more  of  a  holiday  dinner  than  will  extra  diet, 
so  that  a  small  printing  shop  is  one  of  the  most  valuable 


96  RECONSTRUCTION    THERAPY 

adjuncts  of  the  occupation  work  and  every  hospital  of 
fifty  or  more  patients  should  have  one. 

Perhaps  it  may  be  of  interest  and  also  somewhat 
suggestive  if  I  describe  in  detail  some  of  the  menus  which 
have  been  used  on  festive  occasions  at  the  Sheppard  and 
Enoch  Pratt  Hospital.  The  first  menu  consisted  of  two 
cards  on  the  first  of  which  was  printed  a  green  wreath 
formed  of  what  are  known  to  the  printer  as  florets  (a 
little  flower)  arranged  in  an  oval  form  to  represent  a 
wreath  of  holly  surrounding  the  words  "Merry  Christ- 
mas" in  red.  On  the  second  card  the  menu  was  printed, 
also  in  green  and  red.  The  two  cards  were  tied  together 
with  red  ribbon.  Since  this  first  effort  we  have  become 
more  ambitious,  now  make  our  own  rucco  blocks  for 
special  designs,  and  then  touch  up  the  printed  picture 
with  water  color  or  dye,  by  this  means  making  occupa- 
tion for  a  certain  group  of  patients.  We  have  gradually 
accumulated  a  number  of  cuts  purchased  from  the  type 
founder  and  these  can  be  arranged  in  many  attractive 
combinations. 

We  have  also  learned  that  for  certain  holidays,  certain 
color  combinations  are  appropriate,  such  as  yellow 
and  green  for  Thanksgiving,  orange  and  black  for  Hal- 
lowe'en, purple  for  Easter,  though  the  last  is  sometimes 
varied  with  pale  green  and  yellow  to  express  the  idea  of 
spring,  as  shown  by  the  jonquil.  Patriotic  days  naturally 
require  the  use  of  red,  white,  and  blue,  while  St.  Pat- 
rick's Day  must  have  green  in  prominence. 

While  the  use  of  color  has  aroused  interest  we  have  been 
able  to  stimulate  our  patients  still  more  by  the  use  of 
verses,  sayings,  etc.,  appropriate  to  the  anniversary, 
which  are  printed  on  the  menu.  In  the  first  place  various 
members  of  the  staff  began  to  collect  them,  then  patients 
began  to  hand  them  in,  so  that  now  we  have  accumu- 
lated a  fair-sized  store  for  certain  occasions,  but  for  others 
must  still  keep  hunting.  These  inscriptions  vary  from 
the  sublime  to  the  ridiculous  and  include  the  historical. 
We  regard  these  holiday  menus  as  of  great  value  as  stimu- 


AMUSEMENTS  97 

lants  to  a  wider  interest,  and  their  preparation  frequently 
gives  the  occupation  class  several  hours  work. 

In  preparing  these  menus  and  especially  in  finding 
inscriptions  for  them  we  have  been  aided  by  Chambers's 
Book  of  Days,  Bartlett's  Familiar  Quotations,  and  Carey 
and  Jones's  Books  and  My  Food,  but  must  acknowledge 
our  indebtedness  to  many  other  sources,  including 
advertisements. 


CHAPTER  IX 
WORKSHOPS 

It  is  to  be  regretted  that  too  frequently  when  provision 
is  made  for  shops  and  workrooms,  several  very  important 
things  are  not  considered.  In  the  first  place,  shops 
should  have  plenty  of  light,  not  only  to  permit  the  work- 
ers to  see  their  work  properly  and  so  diminish  eye  strain, 
but  to  give  a  cheerful  appearance  to  the  room.  Un- 
doubtedly one  feels  more  like  working  in  a  bright  cheer- 
ful room  than  in  a  dull  one.  For  the  same  reason  the 
place  should  be  made  as  attractive  as  possible.  The 
physician  who  was  showing  me  about  the  splendid  Men's 
Pavilion  at  Bloomingdale  remarked  to  me:  "A  place 
like  this  makes  one  want  to  work,  doesn't  it?"  So  it  did, 
though  there  was  no  occupation  going  on  at  the  time. 

Too  often  do  we  find  shops  placed  in  the  basement 
or  in  some  old  building  whose  original  purpose  has  been 
abandoned.  It  is  better  to  have  a  poorly  adapted  shop 
than  none  at  all,  and  while  very  few  of  our  hospital  mana- 
gers or  trustees  realize  how  important  occupation 
therapy  is  and  therefore  do  not  make  sufficiently  large 
appropriations  to  provide  the  ideal  place,  it  is  wise  to 
make  our  shops  as  attractive  as  possible  even  though 
this  be  difficult. 

If  an  artificial  lighting  system  is  necessary,  and  it 
usually  is  on  dull  days  or  late  winter  afternoons,  the  in- 
direct system  is  undoubtedly  the  best  both  hygienically 
and  aesthetically. 

Like  many  others,  I  believe  that  an  important  function 
of  our  hospitals  is  to  teach  our  patients  how  to  live. 
Doubtless  many  have  heard  of  the  Utica  State  Hospital 
patient  who  thirty  years  ago  refused  to  return  to  her 
home  when  she  had  recovered  until  her  husband  had 

98 


WORKSHOPS 


installed  a  bath  tub.  Undoubtedly,  indirect  lighting 
is  the  most  hygienic  form  and  those  who  have  had  the 
opportunity  of  using  it  know  that  it  is  the  most  pleasant. 


~ 
ft  S 

3   o 
§0 


While  it  is  impossible  to  lay  down  arbitrary  rules  for 
planning  shops,  because  the  kinds  of  crafts  pursued  will 
regulate  the  arrangement,  the  following  descriptions 


100 


RECONSTRUCTION   THERAPY 


may  be  helpful.  It  goes  almost  without  saying  that 
shops  should  be  grouped  together  as  much  as  possible 
in  order  that  the  director  of  teacher  will  have  all  occupa- 
tions concentrated  and  so  avoid  wasting  time  and  effort 
going  from  shop  to  shop. 

Undoubtedly  the  most  luxurious  shops  that  I  have 
seen  are  in  the  Men's  Pavilion  at  Bloomingdale.  The 
Pavilion  consists  of  a  one  story  red  brick  building  a  little 


FIG.  2. — Court  of  men's  occupation  pavilion,  Bloomingdale  Hospital. 
(Courtesy  of  Dr.  William  L.  Russell.) 

distance  from  the  Men's  Wards.  The  inner  walls  are 
of  buff  brick  which  give  a  pleasing  and  bright  appear- 
ance. The  building  is  U-shaped  and  on  the  right  of  the 
entrance  is  the  directors'  office  and  a  small  library.  On 
the  left  is  the  room  for  jewelry  workers.  Directly  oppo- 
site is  a  well-lighted  court  used  for  exhibition  purposes 
with  cases  for  displaying  the  articles  made.  The  right 
side  of  the  U  contains  four  rooms  for  reed  basketry, 
weaving,  bookbinding  and  printing.  The  left  side,  six 
rooms  for  cement  work,  broom  making,  brush  making 


WORKSHOPS 


101 


102  RECONSTRUCTION    THERAPY 

and  chair  caning,  pottery,  art  smithing  and  metal  work, 
and  the  carpentry  shop.  This  arrangement  groups  the 
quieter  occupations  at  the  front  of  the  building,  the 
noisier  ones  at  the  back.  An  excellent  description  of  the 
building  by  the  Director,  Mr.  Louis  J.  Haas,  is  to  'be 
found  in  the  Industrial-Arts  Magazine,  Vol.  v,  p.  516. 

It  will  be  noted  that  in  the  above  building  separate 
rooms  are  provided  for  different  crafts.  At  the  New 
Jersey  State  Hospital  at  Morris  Plains  the  industrial 
building  is  planned  differently.  It  is  a  brick  building 
of  two  stories,  each  floor  being  one  large  room.  There 
are  no  partitions,  each  group  of  workers  in  a  single 
craft  occupying  definite  floor  space,  perhaps  outlined 
by  cupboards  or  something  similar.  This  method  has 
the  advantage  of  making  supervision  easier,  but  the 
possible  disadvantage  of  furnishing  more  distraction 
to  the  worker.  The  lack  of  high  partitions  render  the 
problems  of  light  and  air  less  difficult,  and  the  cost  of 
construction  was  much  less  than  at  Bloomingdale. 

The  Women's  Shops  at  Bloomingdale  are  in  a  building 
originally  erected  to  accommodate  patients,  but  which 
has  been  well  adapted  to  its  present  uses.  The  porches 
have  been  enclosed  with  glass  sash  SON  fhat  pleasant 
and  bright  places  are  provided  for  certain  forms  of  work. 
I  have  also  seen  a  picture  of  another  workshop  where 
enclosed  porches  are  utilized  as  work  rooms.  The 
cheerfulness  of  such  places  is  undoubtedly  a  valuable 
factor  in  aiding  recovery. 

At  Devereux  Mansion,  Dr.  Hall  has  transformed 
what  was  the  barn  or  stables  into  a  bright,  cheerful  and 
convenient  workshop.  The  greater  part  of  one  side  of  the 
building  is  used  as  a  weaving  room.  It  is  large,  with 
a  very  high  ceiling,  probably  twenty  feet  at  least,  and 
has  large  windows  placed  high  up  along  one  side  (the 
north),  which  makes  a  most  pleasant  light  for  the  workers. 
The  other  side  of  the  building  is  divided  into  two  tiers 
of  rooms.  At  the  time  of  my  visit  the  upper  ones  were 
used  for  storage.  The  lower  are  entered  from  the 


WORKSHOPS 


103 


104  RECONSTRUCTION    THERAPY 

weaving  room,  and  are  used  for  individual  workers, 
or  for  such  crafts  as  carpentry,  stenciling  and  cement 
work.  The  latter  has  developed  into  quite  an  important 
industry  although  it  has  not  yet  reached  the  point  to 
which  Dr.  Hall  brought  pottery.  This  has  been  or- 
ganized as  a  commercial  venture  by  Dr.  Hall  and  some 
of  his  "graduates"  and  is  known  as  the  Marblehead 
Pottery.  Dr.  Hall  has  proved  that  it  is  possible  to  alter 
a  rather  unpromising  building  into  an  excellent  shop. 

It  would  seem  that  a  building  erected  on  the  bungalow 
plan  with  rather  high  enclosed  porches,  not  over  ten  feet 
broad  on  three  sides,  could  be  erected  at  a  comparatively 
low  cost  and  would  form  a  delightful  working  place. 
Care  must  be  taken  not  to  make  the  roof  of  the  porch 
so  broad  and  so  low  that  light  is  excluded  from  the  inner 
rooms.  A  second  story  could  be  added  if  necessary. 

The  north  side  should  have  rather  large  windows  to 
admit  all  the  light  possible  to  the  rooms  upon  that  side. 
The  so-called  "daylight"  sash  used  in  factory  construc- 
tion makes  ideal  lighting  conditions. 

It  is  a  good  idea,  frequently  carried  out,  to  have  as 
much  equipment  as  possible  made  by  patients.  As  is 
well  known,  they  take  a  greater  interest  in  doing  work 
when  they  know  the  purpose  for  which  it  is  to  be  used, 
and  those  who  may  require  a  prolonged  residence  in  the 
hospital  will  continue  to  take  pleasure  in  the  fact  that 
they  helped  to  equip  the  building. 

The  plan  as  carried  out  at  Bloomingdale  of  having 
the  noisy  occupations,  carpentry  and  metal  work,  as 
remote  as  possible  from  the  quieter  ones,  such  as  basketry, 
is  an  excellent  one,  and  should  be  kept  in  mind  when 
planning  shops.  On  the  other  hand,  no  dusty  occupa- 
tion, such  as  cement  work,  should  be  placed  close  to  one 
requiring  fine  work.  At  Bloomingdale  this  has  been 
found  to  be  a  mistake  and  apparatus  for  carrying  off  the 
dust  has  been  installed. 

If  it  is  necessary  to  use  basement  rooms  they  should 
be  made  as  bright  as  possible  by  coating  the  walls  and 


WORKSHOPS  105 

ceilings  with  white  paint.  A  water  paint  is  preferable 
as  it  can  be  renewed  frequently  with  but  slight  cost. 

Above  all,  neatness  and  orderly  arrangement  should  be 
insisted  upon  in  every  shop  and  patients  should  be  taught 
to  clear  up  before  the  shop  closes  for  the  day. 

Miss  Tracy  has  recorded  how  the  plan  of  the  workshop 
has  influenced  the  methods  of  her  teaching  in  a  paper 
read  at  the  First  Annual  Meeting  of  the  National 
Society  for  the  Promotion  of  Occupational  Therapy.1 

1  Proceedings  of  First  Annual  Meeting  of  the  National  Society 
for  the  Promotion  of  Occupational  Therapy,  p.  42. 


CHAPTER  X 
OCCUPATIONAL  THERAPY  AND  THE  WAR 

While  there  is  a  direct  relation  between  occupational 
therapy  and  the  war,  many  similar  problems  are  met 
with  in  civil  life.  We  have  industrial  cripples  and 
blind  and  deaf  from  other  causes.  These  form  a  large 
number.  According  to  Mr.  Frank  B.  Gilbreth,1 
Canada's  industrial  cripples  outnumber  those  result- 
ing from  war.  These  should  be  aided  in  becoming  at 
least  partially  self-supporting,  and  should  be  taught 
some  occupation,  which  will  help  them  to  pass  their 
leisure 'time  pleasantly  if  not  profitably.  They  should 
be  taught  how  to  play  as  well  as  how  to  work. 

It  is  of  interest  to  note  that  the  Great  War  has  done 
much  to  emphasize  the  value  of  occupational  therapy. 
In  the  first  place  the  crippled  have  been  taught  methods 
by  which  their  handicaps  may  be  overcome  or  dis- 
counted, and  secondly,  occupational  therapy  has  proved 
extremely  valuable  in  the  treatment  of  those  functional 
disorders  to  which  the  name  "shell  shock"  has  been  given 
(see  page  113). 

It  became  evident  soon  after  the  war  began,  that  the 
number  of  crippled  returning  to  civil  life  would  be  so 
large  that  the  old  plan  of  pensioning  them  would  be  im- 
possible to  carry  Out,  especially  as  the  number  of  able- 
bodied  would  be  too  few  to  support  the  tremendous 
financial  load  of  taxation  which  would  be  necessary. 
The  problem  being  an  economic  one  attracted  more  imme- 
diate attention  than  if  it  had  been  merely  medical,  and 

1  The  Engineer,  The  Cripple  and  the  New  Education.  Journal 
of  The  American  Society,  of  Mechanical  Engineers,  Vol.  xl,  p.  51, 
January,  1918. 

106 


OCCUPATIONAL  THERAPY  AND  THE  WAR      107 

for  this  reason  Monsieur  Herriot,  Mayor  of  Lyons, 
established  two  schools  where  the  mutiles  (crippled)  were 
taught  new  trades,  or  could  learn  to  adapt  themselves 
to  former  ones. 

The  foremost  figure  in  this  work,  however,  has  been 
Dr.  Jules  Amar,  Directeur  Laboratoire  des  Recherches 
sur  le  Travail  Professionel,  62,  Boulevard  St.  Germain, 
Paris,  who  has  attacked  the  subject  with  scientific  knowl- 
edge and  great  common  sense.  With  suitable  apparatus 
he  tests  the  strength  of  the  stump,  the  respiration  (as 
a  part  of  the  patient's  physical  fitness),  the  tactile  sensi- 
bility of  those  blind,  and  so  forth.  He  has  also  devised 
a  very  ingenious  artificial  arm  which  is  said  to  be  quite 
remarkable. 

Doctor  Bourillon,  Directeur  de  1'Institut  National 
Professionel  des  Invalides  de  la  Guerre,  St.  Maurice, 
pursues  the  same  methods  as  Dr.  Amar,  and  utilizes 
apparatus  to  exercise  and  increase  the  strength  of  the 
stump.  These  two  men  stand  pre-eminent,  but  there 
are  a  number  of  others  who  have  done  notable  work  in 
providing  prosthetic  apparatus  for  the  crippled  and  in 
re-educational  methods. 

A  few  of  the  many  names  which  might  be  mentioned 
are  Dr.  Armand  Deltenre  of  the  Therapeutic  and  Ortho- 
pedic Institute  at  Rouen;  Major  Haccourt,  Technical 
Director,  and  Dr.  Dam,  Medical  Director,  L'Institut 
Militaire  Beige  de  Re-Education  Professionelle,  Port 
Villez,  Vernon.  Approximately  fifty  re-educational  es- 
tablishments have  been  organized  in  France. 

In  our  own  country,  Mr.  Frank  B.  Gilbreth,  whose  work 
as  an  efficiency  engineer  had  well  fitted  him  for  this  work, 
has  made  some  very  ingenious  suggestions  and  has  done 
much  to  aid  both  abroad  and  in  this  country.  It  is 
interesting  to  compare  his  method  with  that  of  Profes- 
sor Amar.  Mr.  Gilbreth  believes  in  fitting  the  machine 
to  the  man,  making  whatever  additions  or  adaptations  are 
necessary  to  enable  the  cripple  to  do  efficient  work.  Pro- 
fessor Amar  on  the  other  hand  makes  his  prosthetic 


108  EECONSTRUCTION    THERAPY 

apparatus  in  such  a  way  that  the  man  is  adapted  to  the 
machine.  It  would  seem  that  Mr.  Gilbreth's  is  the 
better  principle. 

In  Canada  remarkable  work  has  been  done  by  the 
Military  Hospitals  Commission,  which  has  established 
schools  for  vocational  training  in  practically  all  of  the 
convalescent  hospitals.  Here  competent  teachers  give  in- 
struction in  various  crafts,  stenography  and  typewriting, 
drawing,  shop  arithmetic,  and  in  fact,  anything  which  will 
aid  the  patient  to  fit  himself  to  earn  a  living.  Several 
have  been  taught  barbering.  All  of  this  work  is  in  charge 
of  Mr.  Thomas  B.  Kidner,  the  Vocational  Secretary, 
and  great  credit  is  due  him  for  the  way  it  has  been 
organized. 

Soon  after  the  declaration  of  war  (August  1,  1914) 
on  August  13,  1914,  the  German  Empress  requested  the 
president  of  the  German  Association  for  the  care  of  Crip- 
ples (Deutsche  Vereinigung  fur  Kriippelftirsorge)  to  con- 
tinue the  work  for  crippled  children. 'and  also  undertake 
the  orthopedic  care  of  the  wounded.  The  organization 
was  in  charge  of  Dr.  Konrad  Bielsalski,  Secretary  of  the 
above  association,  and  practically  the  same  work  is 
carried  on  as  in  other  countries. 

Needless  to  say,  England  has  not  been  behind,  and  a 
special  journal,  Recalled  to  Life  (London,  John  Bale 
Sons  &  Danielson)  records  their  activities. 

As  news  of  this  work  in  progress  abroad  and  in  Canada 
came  to  this  country,  some  of  us  recognized  that  distinct 
advances  had  been  made  over  older  methods  and  that 
here  was  a  splendid  opportunity  for  the  rehabilitation 
of  the  industrial  cripple.  A  number  of  us  began  a  period 
of  more  special  study  and  research.  Among  the  fore- 
most was  Mr.  George  Edward  Barton,  who  for  three 
years  had  conducted  "A  School,  Workshop,  and  Voca- 
tional Bureau  for  Convalescents  known  as  Consolation 
House."1 

1  Consolation  House.  By  its  Secretary,  Isabel  Gladwin  New- 
ton. Trained  Nurse  and  Hospital  Review,  December,  1917. 


OCCUPATIONAL  THERAPY  AND  THE  WAR      109 

Later  with  the  participation  of  the  United  States  in 
the  great  conflict,  others  showed  an  active  interest  in 
the  subject.  Through  the  efforts  of  the  orthopedists 
a  special  branch  of  military  service  was  created,  the 
Department  of  Military  Orthopedic  Surgery.  To  this 
department  was  given  especial  charge  of  the  re- construc- 
tion hospitals,  which  it  was  expected  would  be  erected 
by  the  Government  in  nineteen  of  the  larger  cities.1 

To  the  National  Committee  for  Mental  Hygiene  was 
given  charge  of  the  formation  of  the  psychiatric  units 
and  the  Committee  naturally  made  provision  for  oc- 
cupational treatment  in  them.  In  a  report  to  the  Sur- 
geon-General, Dr.  Thomas  W.  Salmon,  of  this  committee, 
made  certain  Recommendations  for  the  Treatment  of 
Mental  and  Nervous  Diseases  in  the  United  States  Army,2 
in  which  he  states  "None  of  the  methods  available  for 
re-education  are  so  valuable  in  the  war  neuroses  as 
those  in  which  a  useful  occupation  is  employed  as  the 
means  of  training."  For  this  purpose  he  gives  a  list 
for  equipping  shops  "which  is  necessary  at  the  beginning." 

"Smiths'  shop: 

Forges,  tools,  etc.,  for  ten  men. 
Fitting  shop: 

One   screw-cutting   lathe,    one   sensitive  drill,  one  polishing 

machine,  one  electric  motor  1^  h.p.,  swages  and  tools  for 

eight  men. 
Leather  blocking  room : 

Sewing  machine,  eyeletting  machine,  tank,  galvanized  iron 

and  tools. 
Tailors'  shop: 

Three  Singer  machines,  tools  for  ten  men. 
Carpenters'  shop: 

Selected   tools   for   fifteen   men,   bench   screws   and   special 

tools  not  for  general  use,  wood-turner's  lathe. 
Machine  shop: 

Electric  motor,  8>£  h.p.,  with  shafting^  brackets,  etc. 
Cement  shop: 

Metal  molds,  tools  for  twelve  men. 

1  Science,  September  28,  1917. 

2  Psuchialric  Bulletin,  Vol.  ii,  p.  355. 


110  RECONSTRUCTION    THERAPY 

Printing  shop: 

Press  and  accessories. 

General : 

Drilling  machine,   grindstone,   screw-cutting  lathe,   fret-saw 
workers'  machine  and  patterns,  circular-saw  bench. 

Practically   all  gymnasium  apparatus  can  be  made  in 
the  shops  after  the  hospital  is  opened/' 

The  personnel  in  charge  of  such  work  includes  a  Major, 
Chief  of  the  Occupational  Division;  two  Sergeants,  in 
charge  of  shops,  and  the  following  Civilian  Employees : 

Instructors: 

Outdoor  occupations 1  j    ^ 

Indoor  occupations 1  j 

Assistant  Instructors : 

Carpentry  and  wood-carving 1 

Cement  work 1 

Metal  work 1 

Leather  work 1 

Gardening 1 

Printing 1 

Gymnasium 2 

Stenographers 4 

Photographers 1 

Laboratory  technician 1 

16 

These  nineteen  individuals  are  of  a  total  staff  of  234, 
and  six  of  them  (stenographers,  photographer  and 
laboratory  technician)  evidently  have  other  duties  than 
educational.  Dr.  Salmon  also  says:  " The  instructor  for 
bed  occupations  should  be  a  woman,  and  she  should  train 
the  female  nurses  to  assist  her  in  this  kind  of  work." 

A  further  recommendation  of  Dr.  Salmon's  which  is 
of  considerable  interest  is  that  "No  soldiers  suffering 
from  functional  nervous  disorders  be  discharged  from  the 
army  until  at  least  a  year's  special  treatment  has  been  given. 
Furloughs  can  be  given  when  visits  home  will  be  benefi- 
cial, but  the  government  should  neither  evade  the  re- 
sponsibility nor  surrender  the  right  to  direct  the  treat- 
ment of  these  cases.  A  serious  social  and  economic 


OCCUPATIONAL  THERAPY  AND  THE  WAR      HI 

problem  has  been  created  in  England  already  through 
the  establishment  in  its  communities  of  a  group  of  chronic 
nervous  invalids  who  have  been  prematurely  discharged 
from  the  only  hospitals  existing  for  the  efficient  treat- 
ment of  their  illness.  So  serious  is  this  problem  that  a 
special  sanitarium — "The  House  of  Recovery,"  the  first 
of  several  to  be  provided  has  been  established  in  London, 
and  subsidized  by  the  War  Office  for  the  treatment  of 
such  cases  among  pensioners." 

In  another  article  Dr.  Salmon  says:1  "Re-education 
by  physical  means  is  a  valuable  adjunct  to  treatment  in 
recent  cases  but  particularly  in  chronic  cases  who  have 
been  mismanaged  and  in  those  who  are  recovering  from 
long-continued  paralyses,  tics,  mutism  and  gait  dis- 
orders. While  drills  and  physical  exercises  have  their 
specific  uses,  occupation  is  the  best  means.  Non- 
productive occupations  should  be  avoided. 

"Occupations  are  conveniently  classified  as:  (1)  Bed. 
(2)  Indoor.  (3)  Outdoor. 

"1.  Basket-making  and  net-making  are  good  bed  oc- 
cupations for  cases  with  extensive  paralyses,  as  are 
making  surgical  dressings  and  various  minor  finishing 
operations  (sandpapering,  polishing,  etc.)  on  products 
of  the  shops.  All  occupations,  and  especially  those  which 
are  carried  on  by  patients  seriously  incapacitated,  should 
be  regarded  as  only  steps  in  a  process  of  progressive  educa- 
tion. Every  effort  must  be  made  to  prevent  skill  acquired 
in  them  from  being  considered  as  a  substitute  for  full  func- 
tional activity.  Herein  is  an  important  difference  between 
the  "re-education"  of  neurotic  and  orthopedic  cases. 
In  the  latter  the  purpose  is  often  to  make  the  remaining 
sound  limb  take  on  the  functions  of  one  which  is  missing 
or  permanently  disabled.  The  function  -held  in  abeyance 
through  neurotic  symptoms  must  never  be  looked  upon  as 
lost.  It  can  and  must  be  restored  and  if  another  function 

1  Thomas  W.  Salmon.  The  Care  and  Treatment  of  Mental 
Diseases  and  War  Neuroses  ("Shell  Shock")  in  the  British  Army. 
Mental  Hygiene,  Vol.  i,  p.  509,  October,  1917. 


112  RECONSTRUCTION    THERAPY 

is  developed  as  its  surrogate  the  day  of  full  recovery 
is  thereby  postponed.  Bed  occupations,  therefore,  must 
always  be  regarded  as  the  first  steps  in  a  series  which  is 
to  culminate  in  full  activity.  Progress  through  achieve- 
ments constantly  more  difficult  is  the  key-note  of  re- 
education in  the  war  neuroses. 

"2.  A  wide  variety  of  indoor  occupations  should  be 
provided  including  at  the  minimum  carpentry,  wood 
carving,  metal  work  and  cement  work.  Printing,  book- 
binding, cigarette  making,  electric  wiring  and  other 
work  should  be  added  as  opportunities  permit. 

"3.  Farming,  gardening  and  building  operations  are 
desirable  outdoor  occupations.  Where  possible,  wood 
sawing  and  chopping  are  very  desirable  as  is  the  care  of 
stock  not  requiring  much  land  (squabs,  guinea-pigs, 
rabbits,  game,  frogs). 

*  "Before  even  the  simplest  occupation  can  be  engaged 
in  it  is  sometimes  necessary  to  re-educate  paraplegics 
and  ataxies  in  walking  and  co-ordination.  Just  as 
soon  as  possible,  exercises  should  be  replaced  by  pro- 
ductive occupations  which  will  accomplish  the  same 
results  more  quickly  and  more  satisfactorily.  The  same 
is  true  of  gymnastic  exercises  which  in  the  early  steps 
of  treatment  constitute  a  valuable  resource  but  which 
should  be  replaced  by  specially  devised,  useful  tasks. 
Swimming  has  a  unique  place  in  the  treatment  of  gait 
disturbances,  paralyses  and  tics.  One  of  the  first  pieces 
of  construction  undertaken  by  the  outdoor  patients 
at  a  reconstruction  center  should  be  that  of  building  a 
large  concrete  swimming  tank. 

"Hydrotherapy  and  electrotherapy  have  a  distinct 
value  when  they  are  applied  with  absolute  sincerity  and 
full  realization  on  the  part  of  patient  and  medical  officer 
of  the  role  which  they  actually  play  in  the  treatment 
of  functional  nervous  diseases. 

"The  experience  in  English  hospitals  has  demonstrated 
the  great  danger  of  aimless  lounging,  too  many  enter- 
tainments and  relaxing  recreations  such  as  frequent 


OCCUPATIONAL  THERAPY  AND  THE  WAR      113 

motor  rides,  etc.  It  must  be  remembered  that  'Shell 
Shock'  cases  suffer  from  a  disorder  of  will  as  well  as 
function  and  it  is  impossible  to  effect  a  cure  if  attention 
is  directed  to  one  at  the  expense  of  the  other."  As 
Dr.  H.  Crichton  Miller  has  put  it,  " '  Shell  Shock  pro- 
duces a  condition  which  is  essentially  childish  and 
infantile  in  its  nature.  Rest  in  bed  and  simple 
encouragement  is  not  enough  to  educate  a  child.  Pro- 
gressive achievement  is  the  only  way  whereby  manhood 
and  self-respect  can  be  regained."1 

The  Committee  on  Nursing  of  the  Medical  Council 
for  Defense,  made  an  investigation  of  possible  training 
places  for  occupational  workers  and  at  their  request,  I 
submitted  the  outline  of  a  training  course  as  follows: 

The  following  outline  of  suggested  courses  in  training 
in  invalid  occupation  and  occupational  therapy  may  be 
said  to  be  elaborated  from  the  earlier  outline  I  gave  you, 
and  it  should  be  understood  that  neither  represents  my 
ideals.  They  merely  represent  the  minimum  require- 
ments and  it  should  be  possible  to  carry  them  out  in 
any  of  the  hospitals  which  I  indicated  to  you.  It  is,  of 
course,  an  established  fact  that  early  cultural  advantages 
and  training  of  the  pupils  might  make  it  possible  to  con- 
siderably supplement  such  courses,  and  it  may  also  be 
stated  as  an  axiom  that  the  more  "accomplishments" 
an  individual  possesses,  the  greater  will  be  his  capabilities. 
It  is  difficult  to  say  exactly  how  much  time  would  be 
required  to  give  these  courses.  If  it  were  possible  to 
get  college  graduates,  either  men  or  women,  to  take  up 
this  work,  they  could  probably  be  given  in  six  weeks  of 
rather  intensive  work.  Probably  the  same  time  would 
suffice  for  classes  of  trained  nurses.  It  would  seem  ob- 
vious that  just  at  present  the  number  of  men  college 
graduates  and  trained  women  nurses  that  would  be 
available  would  be  very  small  as  they  are  needed  in  other 
branches  of  service. 

It  has  been  found  that  the  personality  of  those  apply- 
ing occupational  therapy  is  of  far  greater  importance 


114  RECONSTRUCTION   THERAPY 

than  skill  in  crafts.  Such  a  person  should  possess  con- 
siderable tact,  common  sense,  and  a  fertility  of  ideas 
and  invention.  The  last  so  that  adaptations  can  be 
made  for  special  cases  and  purposes. 

INVALID  OCCUPATION 

Invalid  occupation  is^intended  chiefly  to  divert  and 
amuse,  keeping  the  mind  of  the  patient  from  dwelling 
upon  his  illness  and  possibly  developing  hypochondriacal 
ideas.  In  certain  cases,  therefore,  the  means  of  invalid 
occupation  may  become  of  therapeutic  importance. 
For  example,  a  card  game  might  be  the  best  method  of 
inducing  a  particular  case  to  exercise  his  fingers. 

Puzzles  and  Catches. — The  manner  of  approach  is  of 
great  importance  and  frequently  requires  the  use  of 
much  tact.  Pupils  should  have  some  instruction  in 
this  branch.  Frequently  the  play  instinct  can  be  utilized 
to  advantage  and  for  this  reason  it  is  desirable  to  have 
the  occupationer  collect  a  number  of  puzzles  and  catches 
of  various  sorts  which  may  be  used  to  "break  the  ice" 
and  create  a  receptive  attitude  in  the  patient. 

Games. — Card  games,  such  as  solitaire,  may  also  be 
used,  and  the  pupils  should  be  taught  at  least  three  of 
these  besides  cribbage,  fan-tan,  hearts,  euchre,  poker, 
whist  and  bridge.  Dominoes,  checkers  and  other  games 
should  also  be  learned. 

String  Work. — On  account  of  its  commonness,  string 
is  a  valuable  material  which  can  be  utilized  in  a  number 
of  ways.  The  pupil  should  be  taught  a  number  of  plain 
and  fancy  knots  and  braids  which  may  be  combined  to 
make  useful  articles,  and  promote  finger  movements. 

Rake  and  ring  knitting  are  modifications  of  the  spool 
knitter  of  childhood,  with  which  bags,  hoods,  sweaters 
and  other  useful  articles  may  be  made.  Hand  and  fore- 
arm movements  are  chiefly  required,  the  finger  move- 
ments being  few. 

Braided  rugs  may  be  made  from  rags.  Some  sewing 
is  also  required. 


OCCUPATIONAL  THERAPY  AND  THE  WAR     115 

Hooked  rugs,  made  on  burlap,  require  less  finger  mo- 
tion than  the  last  but  bring  in  more  movement  of  the 
arm  and  trunk. 

Making  colonial  mats  on  wooden  frames  requires  but 
little  mental  effort  and  can  be  used  to  exercise  the  shoul- 
der and  elbow  especially. 

Weaving  on  wooden  frames  may  utilize  rags  and  affords 
especial  exercise  for  the  fingers. 

Netting  is  of  practical  utility  and  gives  especial  exer- 
cise to  the  flexor  muscles  of  the  upper  extremity. 

A  knowledge  of  knitting,  crocheting  and  tatting  may 
be  desirable  but  it  is  questionable  whether  time  should 
be  taken  for  their  study  during  a  short,  intensive  course 
as  considerable  practice  is  necessary  to  acquire  skill 
sufficient  to  teach  them.  They  might  be  left  for  the 
nurse  to  develop  herself. 

Paper  Work. — Paper  folding  and  cutting  may  be  util- 
ized to  teach  a  knowledge  of  geometrical  forms  and 
design  to  make  patterns,  which  may  be  used  in  wood  or 
metal  work. 

Cardboard  construction  may  be  used  for  the  same  pur- 
pose. It  may  be  easily  conceived  how  useful  such  knowl- 
edge may  be  to  certain  mechanics.  Finger  and  forearm 
movements  will  be  especially  required  for  such  work. 

Basketry. — A  number  of  materials  may  be  used  for 
this  work.  The  utilization  of  those  indigenous  should 
be  emphasized,  and  useful  forms  should  be  taught. 

Basketry  is  especially  useful  for  finger  and  forearm 
movements  and  training  concentration  of  attention. 

Wood  Work. — With  work  bench  and  ordinary  carpen- 
ters' tools  it  is  possible  to  provide  many  problems  which 
may  require  a  great  variety  of  movements,  from  simple 
movements  of  arm  and  forearm,  as  in  chip  carving,  to  those 
using  the  muscles  of  practically  the  whole  body,  as  in 
planing  a  piece  of  hard  wood. 

A  jig-saw  should  form  a  part  of  the  equipment  as  its 
use  is  an  excellent  way  of  training  the  attention  and  the 
pedal  motion  may  be  used  for  leg  exercise,  The  larger 


116  RECONSTRUCTION    THERAPY 

forms  of  foot-power  saws  have  a  wheel  which  gives 
motion  similar  to  the  bicycle  and  could  be  well  utilized 
in  certain  cases  of  functional  paralyses.  Sand  papering, 
the  use  of  the  wood  rasp,  brace  and  bit,  hammer,  etc., 
all  have  definite  value  in  exercising  special  groups  of 
muscles.  The  student  should  be  encouraged  to  work 
out  a  number  of  these  unassisted. 

Metal  Work. — While  a  proper  study  of  metal  work  will 
require  a  considerable  period,  certain  simple  forms  can 
be  taught  which  have  a  definite  value  in  muscle  training 
and  which  will  perhaps  appeal  to  certain  workers  who 
would  not  be  attracted  by  anything  else. 

Pierced  metal,  as  for  plain  escutcheons,  will  use  but 
little  more  than  arm  movements.  Hammered  metal 
will  require  arm,  trunk  and  possibly  leg  muscles,  depend- 
ing upon  the  character  of  the  piece  made. 

Plastic  Work. — The  chief  value  of  clay  modeling  is 
the  variety  of  finger  motions  required  so  that  they  are 
exercised  without  the  fatigue  consequent  upon  more 
stereotyped  movements.  While  it  is  unlikely  that  a 
St.  Gaudens  will  be  found  among  the  patients,  a  knowl- 
edge of  how  to  express  one's  self  in  form  is  of  value. 
Modeling  is  required  commercially  for  hardware,  light- 
ing fixtures,  jewelry,  etc.,  so  that  this  training  may  be 
helpful  to  some  patients.  Oil  clay,  plasticine,  etc., 
should  be  provided  and  pupils  should  be  taught  the  prin- 
ciples of  taking  plaster  casts. 

Sufficient  cement  work  should  also  be  given  so  that  its 
possibilities  are  understood. 

School  Work. — Under  this  term  may  be  included 
mechanical  drawing,  shop  arithmetic,  stenography, 
bookkeeping,  penmanship,  and  any  other  similar 
branches.  In  a  short  course,  it  would  be  impossible  to 
expect  pupils  to  become  sufficiently  expert  to  properly 
teach  any  of  these  branches.  They  could,  however, 
within  a  very  short  time,  probably  in  one  lesson,  be 
taught  the  principles  and  shown  the  manner  of  using 
books  of  instruction.  In  a  sufficiently  large  unit 


OCCUPATIONAL  THERAPY  AND  THE  WAR      117 

specialists  on  such  subjects  could  be  members  of  the 
staff. 

Typewriting  should  be  included  in  the  above  list 
and  various  attachments  to  be  used  by  cripples  (or  labor- 
saving  devices)  should  form  part  of  the  equipment. 

In  all  of  the  above  work,  talks  on  the  source,  possi- 
bilities, etc.,  of  materials,  or  literary  references,  may 
make  the  subject  more  interesting  to  the  pupils  and  make 
firmer  associations.  The  course  should  also  include  the 
following : 

Lectures. — Definitions  and  uses  of  Invalid  Occupa- 
tion, Occupational  Therapy  and  Vocational  and  Re- 
vocational  Training;  psychology  of  recovery  by  occupa- 
tion; the  value  of  "hobbies;"  manner  of  approaching 
patients;  the  use  of  puzzles  and  catches;  the  utilization 
of  waste;  fatigue  and  its  dangers;  bones,  muscles  and 
joints  (if  a  knowledge  of  their  mechanism  is  lacking). 

Games. — I  presume  that  games,  such  as  catch,  volley 
ball,  etc.,  will  be  in  charge  of  the  Y.  M.  C.  A.  directors. 
The  possibilities  of  these  for  restoring  function  should 
be  kept  in  mind,  and  should  be  pointed  out  to  the 
pupils. 

OCCUPATIONAL  THERAPY 

While  the  above  indicates  some  of  the  possibilities  of 
muscle  training  afforded  by  craft  work,  there  are  many 
which  must  be  worked  out  for  individual  patients. 
Such  work  has  great  value  as  the  patient's  attention  is 
directed  to  an  object  and  away  from  himself,  and  he 
learns  motion  unconsciously  and  naturally. 

Certain  cases  may  require  other  measures,  so  that 
instruction  should  be  given  in  massage,  hydrotherapy, 
FrenkePs  movements,  etc.  This  should  be  given  to 
another  group  than  the  craft  workers. 

A  course  in  massage  should  be  given  by  a  qualified 
teacher,  and  will  require  from  eighteen  to  twenty-four 
hours. 


118  RECONSTRUCTION   THERAPY 

A  course  in  hydrotherapy  would  require  from  twelve  to 
eighteen  hours. 

As  these  are  given  by  prescription  of  the  physician,  the 
mental  qualifications  of  such  pupils  are  not  necessarily 
so  high  as  for  the  course  in  Invalid  Occupation. 

The  orthopedists,  or  such  men  as  Dr.  Win.  J.  M.  A. 
Maloney  or  Dr.  Shepherd  Ivory  Franz,  are  much  better 
qualified  to  detail  the  requirements  for  a  course  in  move- 
ments than  myself,  and  I  would  suggest  that  they  be 
consulted. 

It  is  to  be  emphasized  that  utility  should  be  the 
dominant  principle  of  every  piece  of  work  undertaken. 
Unless  this  point  is  emphasized  the  patients  are  very 
apt  to  regard  the  work  which  is  given  them,  especially 
the  bed  work,  as  "trifling."  It  will  probably  be  well 
in  many  instances  to  explain  the  object  which  it  is  hoped 
will  be  attained,  for  example,  to  exercise  certain  groups 
of  muscles. 

VOCATIONAL  RE-EDUCATION 

While  the  major  part  of  such  instruction  must  be  in 
the  hands  of  "technicians,"  it  is  believed  that  the  patient 
can  be  prepared  to  take  up  such  work  by  the  occupa- 
tional teacher  better  than  .by  the  technician,  who  has 
not  quite  so  broad  an  education  and  therefore  cannot 
take  such  a  comprehensive  view  of  the  subject  as  can 
the  former.  Many  patients  will  be  able  to  resume  for- 
mer occupations  after  some  instruction  and  practice 
in  the  use  of  prosthetic  apparatus.  Others  must  be 
taught  a  new  trade  or  occupation  and  learn  to  adapt 
themselves  to  it  with  the  use  of  apparatus. 

It  is  necessary  that  close  touch  be  kept  with  the  various 
shops  which  are  working  under  active  commercial  con- 
ditions. Arrangements  should  be  made,  as  I  believe 
they  can,  that  the  crippled  soldiers  may  have  actual 
shop  experience  before  being  discharged  to  civil  life. 

The  Federal  Board  of  Vocational  Education  can  prob- 
ably aid  greatly  in  assisting  the  technicians  to  keep  up 


OCCUPATIONAL  THERAPY  AND  THE  WAR      119 

their  knowledge  of  better  trade  methods.  Men  like 
Mr.  Frank  B.  Gilbreth,  the  efficiency  engineer,  can  also 
aid  greatly  in  devising  labor  saving  methods  and  devices. 


The  Red  Cross  also  formed  plans  to  provide  invalid 
occupation  as  a  part  of  its  nursing  service,  and  were  aided 
by  the  presentation  to  them  of  a  very  comprehensive 
outline  by  Miss  Sarah  Atherton,  a  social  service  worker 
of  Wilkes-Barre,  Pa. 

Before  any  definite  plans  were  published  by  the  United 
States  Government,  the  Chicago  Chapter  of  the  Red 
Cross  gave  a  six  week's  course  at  the  Henry  B.  Favill 
School  of  Occupations,  Illinois  Society  for  Mental 
Hygiene,  under  the  direction  of  Mrs.  Eleanor  Clarke 
Slagle. 

This  was  attended  by  twenty  young  women,  not  neces- 
sarily nurses,  who  preferably  had  had  social  service  train- 
ing or  special  work  in  sociology  or  social  economics. 

The  crafts  taught  were: 

Elementary  bookbinding; 

Weaving,  both  simple  and  advanced; 

Basketry; 

Rush  seating; 

Cane  work; 

Leather  tooling. 

Rug  making,  braided,  hooked  and  crocheted. 

The  Chicago  School  of  Civics  and  Philanthropy  later 
gave  a  course  in  conjunction  with  the  above  as  follows: 

(Winter  Term,  January  2  to  March  15) 

Lecture  Courses: 

Administration  of  charitable  institutions — 2  hours. 
Medical  agencies  in  relation  to  social  service — 2  hours. 
Industrial  and  public  hygiene — 2  hours. 
Principles  of  case  work — 1  hour. 


120  RECONSTRUCTION   THERAPY 

Technical  Courses: 

Kinesiology — 2  hours. 
Folk  dancing — 3  hours. 
Gymnastics — 4  hours. 
Games — 2  hours. 
Hand  work — 15  hours. 

(Weaving,  cement  work,  bookbinding,  wood  work  (bench 
work)  metal  work,  chair  caning,  rush  seating,  furniture 
making,  coping  saw  work.) 

(Spring  Term,  March  25  to  June  7) 
Lecture  Courses: 

Principles  of  case  work — 1  hour. 
The  psychology  of  play — 1  hour. 
Psychopathic  principles  in  occupational  and  recreational 

treatment — 2  hours. 

Hospital  organization  and  management — 1  hour. 
Technical  Courses: 

Kinesiology — 2  hours. 

Organization  of  occupational  and  recreational  departments 

— 1  hour. 

Folk  dancing — 3  hours. 
Gymnastics — 4  hours. 
Games — 2  hours. 
Hand  work — 15  hours. 

(Weaving  (continued),  wood  work  (bench  work)  basketry, 
sewing,  wood-carving,  leather  work,  brush  making,  chair 
caning,  rush  seating,  and  furniture  repairing,  elementary 
mechanical  drawing  and  designing.) 

At  Simmons  College  in  Boston,  Miss  Susan  E.  Tracy 
gave  a  course  of  ten  lessons  in  occupational  therapy,  a 
number  of  nurses  taking  this  being  attached  to  the  base 
hospital  unit  of  the  Boston  City  Hospital. 

Meantime  those  interested  in  other  special  branches  of 
medicine  had  been  active,  and  the  Surgeon -General's 
Office  perfected  elaborate  plans  for  the  re-education  of 
those  soldiers  who  returned  handicapped. 

While  much  investigation  was  under  way  by  the 
Surgeon-General's  and  other  governmental  departments, 
no  active  steps  for  the  rehabilitation  of  wounded  soldiers 
and  Bailors  were  taken  until  October  6,  1917,  when 
the 'war  "risk  insurance  bill  was  passed  containing  the 
following  section: 


OCCUPATIONAL  THERAPY  AND  THE  WAR      121 

Section  304  reads  as  follows: 

That  in  cases  of  dismemberment,  of  injuries  to  sight  or  hearing, 
and  of  other  injuries  commonly  causing  permanent  disability,  the 
injured  person  shall  follow  such  course  or  courses  of  rehabili- 
tation, re-education,  and  vocational  training  as  the  United  States 
may  provide  or  procure  to  be  provided.  Should  such  course  pre- 
vent the  injured  person  from  following  substantially  gainful  oc- 
cupation while  taking  same,  a  form  of  enlistment  may  be  required 
which  shall  bring  the  injured  person  into  the  military  or  naval 
service.  Such  enlistment  shall  entitle  the  person  to  full  pay 
as  during  the  last  month  of  his  active  service,  and  his  family 
allowances  and  allotment  as  hereinbefore  provided,  in  lieu  of  all 
other  compensation  for  the  time  being. 

In  case  of  his  willful  failure  properly  to  follow  such  course 
or  so  to  enlist,  payment  of  compensation  shall  be  suspended  until 
such  willful  failure  ceases  and  no  compensations  shall  be  payable 
for  the  intervening  period. 

This,  it  will  be  noted,  makes  no  appropriations,  so 
that  it  is  practically  inoperative.  It  was  claimed, 
however,  that  this  section  placed  the  care  and  responsi- 
bility for  the  rehabilitation  of  United  States  disabled 
soldiers  and  sailors  upon  the  War  Risk  Bureau  of  the 
Treasury  Department.  Obviously,  other  Governmental 
Departments,  such  as  the  War  and  Navy,  were  more 
concerned  with  the  care  and  training  of  men  and  were 
better  qualified  to  carry  these  out  than  the  War  Risk 
Bureau.  The  Federal  Board  of  Vocational  Education 
showed  an  active  interest  in  the  subject,  and  two  of  its 
research  workers,  Dr.  John  Cummings  and  Miss 
Elizabeth  G.  Upham  wrote  the  greater  part  of  Bulletins 
5  and  6,  dealing  with  the  subject. 

Senate  Document  No.  173  which  was  transmitted 
by  Mr.  Newton  D.  Baker,  Secretary  of  War,  on  February 
4,  1918,  gives  the  plans  of  the  Surgeon-General  of  the 
Army  for  the  Rehabilitation  and  Vocational  Education 
of  Crippled  Soldiers  and  Sailors.  The  original  memo- 
randum had  been  sent  to  Mr.  Baker  November  7,  1917, 
and  was  folio  wed.  by  additional  memoranda,  December 
4,  1917.  In  these,  elaborate  and  admirably  conceived 
plans  were  made  for  the  functional  and  vocational  educa- 


122  RECONSTRUCTION    THERAPY 

tion  of  wounded  soldiers.  A  receiving  hospital  was 
planned  to  be  located  on  Staten  Island  or  near  any  other 
receiving  ports  that  might  be  selected.  At  this  hospital 
the  patient's  vocational  and  social  history  was  to  be 
taken  on  prescribed  blanks,  and  he  would  also  be  ex- 
amined by  the  proper  medical  officer.  The  patient  might 
be  transferred  to  one  of  the  hospitals  in  his  home  district, 
or  if  fit  to  pursue  his  former  occupation,  would  be  recom- 
mended for  discharge.  If  the  patient  had  attained  the 
maximum  curative  results  possible,  but  was  unable 
to  continue  his  former  occupation,  the  vocational  officer 
was  to  direct  what  occupations  were  possible  for  him. 
The  patient  would  then  be  sent  to  a  general  hospital 
in  his  home  district,  and  from  there  sent  to  the  school 
selected  for  his  further  training.  Those  who  were  too 
badly  crippled  to  follow  any  occupation,  even  after 
training,  were  to  be  sent  to  a  general  hospital  -in  their 
home  district,  or  might  be  discharged  to  the  care  of 
capable  relatives  or  friends. 

Excellent  plans  were  made  for  vocational  training, 
and  commercial  schools  were  to  be  established  at  the 
hospitals.  Training  in  agriculture  and  the  professions 
was  to  be  carried  on  at  schools  already  established. 
Monetary  assistance  would  be  given  when  necessary, 
and  a  medical  officer  would  be  sent  to  have  charge  of 
such  men.  It  was  also  planned  to  have  an  employment 
agent  at  each  hospital  who  might  secure  positions  for 
the  men  when  they  should  become  qualified.  While 
the  whole  plan  was  tentative,  its  details  were  well  worked 
out.  The  Document  also  contains  other  matter  of 
interest. 

On  January  14,  1918,  a  conference  was  held  in 
Washington,  attended  by  representatives  of  the  War, 
Navy,  Interior,  Treasury,  and  Labor  Departments, 
the  Federal  Board  of  Vocational  Education,  the  Public 
Health  Service,  Council  of  National  Defense,  Red  Cross, 
and  a  number  of  others,  at  which  a  committee  was  ap- 
pointed to  draft  a  bill,  which  was  reported  to  the  con- 


OCCUPATIONAL  THERAPY  AND  THE  WAR      123 

ference  on  January  21,  1918.  'This  bill  repealed  the 
above  quoted  section,  and  created  a  Board  for  Vocational 
Rehabilitation  to  be  composed  of  one  representative 
respectively  from  the  Department  of  War,  Navy, 
Treasury,  Labor,  and  the  Federal  Board  of  Vocational 
Education.  These  were  to  serve  without  compensation, 
but  were  to  be  re-imbursed  for  any  necessary  expenses. 
It  was  authorized  to  organize  three  advisory  committees 
on  Agriculture,  Labor,  and  Commerce  and  Manufacture, 
'the  members  thereof  to  serve  without  compensation, 
but  to  be  paid  their  necessary  expenses.  The  bill 
provided  for  the  co-operation  of  all  the  departments 
concerned  and  for  the  medical  care  of  the  men  under 
the  respective  departments  of  the  War  and  Navy.  An 
appropriation  of  $200,000  was  provided  for  the  fiscal 
year  ending  June  30,  1918.  This  bill  was  not  passed 
and  another  was  introduced  and  passed,  which  put  this 
work  under  the  Federal  Board  of  Vocational  Education. 

In  the  meantime  the  Orthopedic  Division  of  the 
Surgeon-General's  Office  had  created  the  position  of 
Reconstruction  Aide,  of  which  there  were  two  classes. 
The  first  were  to  give  massage  and  various  forms  of  ex- 
ercise, the  second  to  give  invalid  occupation.  The 
requirements  for  these  aides,  especially  as  to  personality, 
were  rather  exacting.  The  recompense  was  quite  small, 
but  fifty  dollars  per  month  with  maintenance  being 
paid  for  home  duty,  with  an  increase  of  ten  dollars  for 
foreign  duty.  Courses  given  at  Teachers  College  and 
Franklin  Union  were  endorsed  and  a  school  was  planned 
in  Washington  to  be  conducted  by  Miss  Marguerite 
Sanderson  under  the  supervision  of  the  Orthopedic 
Division. 

Without  doubt  the  most  constructive  work  has  been 
that  carried  on  at  the  Red  Cross  Institute  for  Crippled 
and  Disabled  Men  in  New  York  under  the  direction 
of  Mr.  Douglas  C.  McMurtrie.  Through  the  gener- 
osity of  Mr.  Jeremiah  Milbank  who  gave  $50,000  and 
the  use  of  a  building,  it  has  been  possible  to  create  a 


124  RECONSTRUCTION    THERAPY 

splendid  institution.  A  number  of  research  workers 
have  made  special  studies  which  are  generously  shared 
with  others  through  the  Institute's  "  Publications." 
In  discussing  the  work  of  the  Institute  Mr.  McMurtrie 
says:1 

"It  is  planned  that  the  work  of  the  Institute  in  the 
vocational  rehabilitation  of  crippled  men  shall  be  perma- 
nent, for  it  must  be  borne  in  mind  that  the  problem  of 
the  industrial  cripple  is  the  greater,  numerically  consid- 
ered, than  that  of  the  crippled  soldier. 

"The  Institute  has  no  official  arrangement  with  the 
national  authorities  relative  to  the  utilization  of  its  facili- 
ties in  the  reconstruction  of  war  cripples.  Had  it  waited 
for  such  an  agreement,  its  work  would  not  yet  have  been 
under  way.  But  the  Institute  is  confident  that,  in  work- 
ing out  the  national  scheme  of  re-education,  existing 
facilities  of  real  value  cannot  fail  to  be  utilized.  The 
present  effort  is  solely  to  make  our  facilities  worth 
offering,  at  a  time  when  other  plans  may  exist  on  paper 
alone.  This  our  duty  is  conceived  to  be." 

It  had  been  my  intention  to  include  a  short  bibli- 
ography of  works  relating  to  the  war  and  occupation 
therapy  besides  those  already  quoted,  but  the  literature 
has  grown  to  large  proportions.  Also  extensive  bibliog- 
raphies have  already  been  published  in  other  places;  there- 
fore, the  list  of  works  pertaining  to  the  rehabilitation  of 
disabled  soldiers  and  sailors  has  been  greatly  curtailed. 

The  best  summary  which  has  yet  appeared  is  by  Dr. 
John  Cummings  of  the  Federal  Board  of  Vocational 
Education,  published  as  Senate  Document  No.  166, 
and  as  Bulletin  No.  5  of  the  Board,  entitled  Vocational 
Rehabilitation  of  Disabled  Soldiers  and  Sailors.  This 
contains  a  splendid  bibliography. 

An   earlier   publication,    The  War  Cripple,2  by  Mr. 

1  The  Organization,  Work  and  Method  of  the  Red  Cross  Insti- 
tute for  Crippled  and  Disabled  Men. 

2  Columbia  War  Papers,  Series  1,  No.  17,  Columbia  University, 
New  York,  1917. 


OCCUPATIONAL  THERAPY  AND  THE  WAR      125 

Douglas  C.  McMurtrie,  is  also  excellent.  Mr.  McMurtrie 
has  also  compiled  a  bibliography  of  The  War  Cripple.1 

In  the  Monthly  Review  (September,  1917)  of  the 
Bureau  of  Labor  Statistics,  U.  S.  Department  of  Labor, 
there  is  a  very  complete  bibliography  of  Vocational 
Education,  and  Employment  of  the  Handicapped,  with 
Special  Reference  to  Crippled  Soldiers,  revised  to  October 
12,  1917.  All  three  of  these  are  easily  procurable. 

Besides  the  above,   the  following  are  of  interest: 

BIBLIOGRAPHY 

Alden,  Percy.  What  France  is  Doing  for  Her  Crippled  Soldiers 
and  Sailors.  Progress,  Vol.  xii,  January,  1917.  Reprinted  in 
Monthly  Review  of  Bureau  of  Labor  Statistics,  Vol.  iv,  p.  851, 
June,  1917. 

Devine,  Edward  T.  The  Inter-allied  Conference.  The  Survey, 
September  29,  1917,  p.  566. 

McMurtrie,  Douglas  C.  Crutches  into  Ploughshares.  The 
Survey,  November  3,  1917,  p.  105. 

Merchant,  F.  W.  The  War  and  Industrial  Education  in 
Canada.  Manual  Training  Magazine,  Vol.  xix,  p.  117,  December, 
1917. 

Re-education  and  Rehabilitation  of  Cripples  Maimed  and 
Otherwise  Disabled  by  War.  Journal  of  the  American  Medical 
Association,  Vol  Ixix,  p.  63,  July  7,  1917. 

Rehabilitating  the  Soldier  after  the  War.  Ibid.,  Vol.  Ixx,  p.  628, 
March  2,  1917. 

The  German  Plan  for  Care,  Re-education  and  Return  to  Civilian 
Life  of  Disabled  Soldiers  and  Sailors.  Ibid.,  Vol.  Ixx,  p.  379, 
February  9,  1918. 

Vocational  Training  for  Disabled  Soldiers  in  Canada.  Monthly 
Review  of  Bureau  of  Labor  Statistics,  Vol.  iv,  pp.  867-874,  June, 
1917. 

1  Publications  of  the  Red  Cross  Institute  for  Crippled  and 
Disabled  Men,  No.  1. 


CHAPTER  XI 
PROSTHETIC  APPLIANCES 

Doubtless,  Mr.  Occupational  Director,  in  traveling 
through  life  you  have  seen  a  cripple  on  the  street  or  by 
the  roadside,  and  have  thought  him  unfortunate  in  not 
being  able  to  work.  Or  again,  you  have  seen  one 
so  maimed  and  disfigured  that  he  was  painful  to  look 
upon.  Doubtless,  you  have  occasionally  had  the  wish 
that  you  might  do  something  to  help  these  unfortunates, 
but  stress  of  other  matters,  or  a  feeling  of  the  bigness  of 
the  task,  has  caused  you  to  defer  any  plans  you  may  have 
made.  In  every  community,  large  or  small,  there  are 
individuals  who  are  crippled  or  deformed  in  some  way 
or  other.  It  may  be  that  they  only  need  glassing  to 
increase  their  efficiency  and  working  ability.  A  knowl- 
edge of  some  of  the  mechanical  aids  which  have  been 
devised  to  help  this  group  may  be  useful  at  some  time 
or  other  and  increase  your  efficiency;  therefore,  I  tender 
no  apology  for  introducing  the  above  subject. 

This  term  while  ordinarily  used  to  include  only  those 
things  which  are  fitted  to  the  body  to  supply  missing 
members,  either  for  aesthetic  or  practical  purposes,  is 
here  used  in  a  broader  sense  to  include  all  appliances, 
whether  attached  to  the  person  or  not,  which  may 
in  any  way  aid  the  crippled. 

In  the  beginning  it  may  be  stated  that  great  difficulty 
has  been  found  in  obtaining  information,  a  difficulty 
which  it  is  hoped  will  soon  be  overcome  through  the 
researches  of  a  laboratory  which  has  been  established 
in  connection  with  the  Surgeon-General's  Office. 

Up  to  date,  however,  it  has  not  been  possible  to  obtain 
much  information  from  those  in  charge  of  the  laboratory 

126 


PROSTHETIC    APPLIANCES  127 

and  the  most  satisfactory  sources  have  been  the  manu- 
facturers of  the  various  appliances.  Naturally,  the  in- 
formation thus  obtained  has  not  been  tempered  by 
unfavorable  criticism.  It  is  but  just  to  state,  however, 
that  I  have  found  no  case  of  misrepresentation,  and  in 
a  number  of  instances  have  felt  that  the  manufacturer 
has  been  quite  modest  in  his  claims.  What  was  most 
lacking  has  been  information  as  to  defects  or  weaknesses, 
which  the  maker  could  be  no  more  expected  to  point  out 
than  a  mother  the  defects  of  her  offspring. 

Artificial  legs  are  the  first  form  of  prostheses,  which 
come  to  mind.  The  simplest  form  is  the  peg-leg,  consist- 
ing of  two  pieces  of  hickory  running  up  each  side  of  the 
stump,  and  set  in  a  block  or  base  forming  the  foot.  The 
outer  or  longer  strip  extends  to  the  waist,  to  which  it 
is  attached  by  a  belt.  The  inner  ends  slightly  below 
the  crotch.  The  stump,  in  thigh  amputations,  rests 
on  a  pad  placed  on  a  wooden  support  held  in  position  by 
the  two  side  strips.  When  the  amputation  is  below  the 
knee,  the  leg  is  flexed  and  the  patient  kneels  on  the  pad. 
These  peg-legs  are  comparatively  cheap,  about  $10.00, 
but  are  unsightly.  Certain  of  the  laboring  class  prefer 
them  to  the  more  elaborate  and  more  expensive  forms 
owing  to  the  ease  of  repair,  which  may  become  frequently 
necessary  with  rough  usage.  Another  form  of  peg-leg 
is  turned  and  has  a  socket  into  which  the  stump  fits. 
These  are  probably  more  comfortable  and  are  more  ex- 
pensive costing  as  high  as  $65.00.  Still  other  forms 
are  carved. 

A  very  ingenious  peg-leg  for  temporary  use  which  has 
a  number  of  advantages,  is  described  in  the  Military 
Surgeon.1  As  the  article  states:  " In  leg  amputations, 
early  functional  use  as  a  requisite  for  end  bearing  has 
already  been  discussed.2  To  provide  properly  for  this, 
some  form  of  temporary  appliance  must  be  supplied  as 
soon  as  the  stump  becomes  sufficiently  hardened  by  the 

iVol.  xlii,  p.  490,  April,  1918. 

2  Military  Surgeon,  Vol.  xlii,  p.  164,  February,  1918. 


128  RECONSTRUCTION   THERAPY 

routine  treatment  prescribed.  The  use  of  such  an  appli- 
ance also  shortens  the  period  of  incapacity  for  work 
and  thus  enables  the  vocational  treatment  to  be  begun 
much  earlier.  The  benefit  to  the  patient's  morale  is 
obvious."  Also,  it  is  easily  fitted  by  the  surgeon,  quickly 
replaced  when  any  change  occurs  in  the  stump,  and  is  of 
slight  weight.  While  more  exact  directions  are  given 
in  the  original,  its  application  may  be  described  as 
follows :  Two  wooden  side  strips  or  supports,  attached 
to  the  foot-piece  are  prepared  in  advance.  A  piece  of 
quarter  inch  felt  is  fitted  about  the  stump,  the  edges 
stitched  together,  and  a  2-inch  cuff  turned  down  at 
the  upper  end.  When  fitted  to  a  thigh  stump  the  upper 
edge  is  brought  against  the  ischium,  the  patient  holding 
the  felt  against  this  point  by  means  of  traction  on  a  piece 
of  bandage  passing  under  the  perineum.  A  single  5- 
inch  plaster-of-Paris  roller  is  passed  over  the  felt,  except- 
ing the  cuff,  and  a  5-inch  plaster  plate  is  applied  on  the 
inner  side,  also  pressed  against  the  ischium.  A  short 
piece  of  webbing  is  attached  to  the  front  of  the  cast 
and  a  longer  piece  at  the  back  by  turns  of  the  bandage 
so  that  when  joined  by  a  buckle  this  strap  goes  over  the 
opposite  shoulder  to  hold  the  socket  against  the  stump. 
The  wooden  side  pieces  are  then  laid  in  position  and  are 
held  in  place  by  turns  of  the  plaster-of-Paris  bandage. 
In  some  cases  there  may  be  chafing  of  the  shoulder  which 
can  be  avoided  by  an  ingenious  arrangement  of  cords 
and  pulleys  made  from  a  pair  of  suspenders.  The  stump 
may  be  protected  or  padded  by  bandaging  with  Japanese 
crepe.  For  temporary  use  it  does  not  seem  possible  to 
equal  this  very  ingenious  device.  Its  cheapness  is  also 
very  much  in  its  favor. 

To  the  better  and  more  complicated  legs  is  a  great 
advance  both  in  appearance  and  pric6.  I  have  seen  a 
man  with  two  artificial  legs  walk  so  well  that  I,  who 
thought  that  he  had  one  natural  leg,  could  not  tell  which 
one  was  artificial.  This  I  considered  a  strong  endorse- 
ment of  the  mechanical  action  of  the  leg.  This  leg,  the 


PROSTHETIC   APPLIANCES 


129 


Hanger,  and  the  Rowley  leg  (Figs.  5  and  6)  have  been 
used  very  extensively  by  the  French  and  the  British. 
The  former  has  a  mechanical  foot  and  ankle  action,  the 
latter,  a  mechanical  ankle  and  rubber  foot.  Each  costs 


J 


about  $100.00.  Other  legs  have  sponge  rubber  feet  with- 
out mechanical  ankle  action,  as  the  Marks.  There  are 
also  forms  having  pneumatic  or  felt  feet.  Each  kind 
has  its  advocates.  It  is  probable  that  the  form  to 


130 


RECONSTRUCTION    THERAPY 


which  a  cripple  first  becomes  accustomed  will  be  his 
favorite  and  attempts  to  get  him  to  use  another  will  be 
unsuccessful. 


FIG.  6. — The  Rowley  leg. 


An  adjustable  leg  has  recently  been  introduced,  the 
mechanical  features  apparently  being  sacrificed,  but  this 
leg  does  not  seem  to  me  to  be  so  good  as  the  others. 


PROSTHETIC    APPLIANCES  131 

There  is  one  form  of  leg  which  has  what  is  called  a 
slip  socket,  there  being  an  inner  socket,  fitting  closely 
about  the  stump,  hung  from  the  attachment  about  the 
thigh.  It  is  claimed  that  this  is  more  comfortable  and 
less  likely  to  injure  the  stump  than  those  having  a  single 
socket. 

Red  willow  is  said  to  be  the  best  material  for  sockets, 
but  a  few  prefer  one  made  of  raw  hide.  A  plaster  cast 
is  usually  made  of  the  stump,  and  the  socket  whether  of 
wood,  leather,  or  raw  hide  is  fitted  accurately  to  it. 
Special  socks  are  worn  so  that  the  skin  of  the  stump  will 
not  become  irritated.  The  slip  socket  is  claimed  to 
avoid  this  absolutely.  Sometimes  the  stump  shrinks 
so  that  it  may  be  necessary  to  wear  a  number  of  these 
socks,  or  in  extreme  cases  to  have  a  new  socket  made.1 

It  is  generally  conceded  that  the  best  mechanical  arm 
for  finer  movements  is  the  Games  (Figs.  7  to  9).  It  is 
expensive,  costing  about  $250.00  and  cannot  be  used  for 
any  heavy  work.  For  the  finer  movements,  however, 
it  seems  to  be  the  best.  I  have  seen  a  man  using  two 
of  these  arms  enter  a  room  carrying  his  hat  in  one  hand, 
his  bag  in  the  other,  lay  each  down  and  go  through  other 
movements  without  any  of  us  recognizing  that  he  had 
not  his  natural  members.  This  same  man  later  demon- 
strated how  he  could  take  off  and  put  on  his  necktie  and 
collar,  use  a  typewriter  and  perform  many  other  acts 
which  I  had  thought  impossible  for  him  to  do.  The 
first  was  accomplished  with  a  small  instrument  like 
an  elongated  loop  glove  buttoner.  The  typewriting  by 
means  of  a  rubber  tipped  pencil  held  in  each  hand. 

The  illustrations  of  Dr.  Amar's  patients  which  are 
reproduced  here  (Figs.  11  and  12)  show  how  much  can 
be  done  with  the  arm  which  he  has  elaborated.  It  ap- 
pears to  compare  very  favorably  with  the  Carnes  arm. 

1  For  further  information  concerning  artificial  legs  see  Principles 
of  Design  and  Construction  of  Artificial  Legs.  By  Captain  Philip 
Wilson,  U.  S.  R.  Publications  of  the  Red  Cross  Institute  for 
Crippled  and  Disabled  Men,  Series  2,  Number  2,  July  10,  1918. 


132  RECONSTRUCTION   THERAPY 


FIG.  7. — Games  artificial  arm. 


PROSTHETIC    APPLIANCES 


133 


FIG.  8. — Games  artificial  arm. 


134 


RECONSTRUCTION   THERAPY 


PROSTHETIC    APPLIANCES 


135 


136  RECONSTRUCTION    THERAPY 

Before  the  elaborate  mechanical  arms  come  the  so- 
called  utility  arms  which  may  consist  of  two  hooks  held 
together  by  strong  springs  or  rubber  bands,  and  which 


FIG.   10. — The  Dorrance  hook  (closed  and  open). 

may  be  separated  by  a  cord  attached  to  the  shoulder 
of  the  opposite  side.  There  are  several  makes  of  this 
which  is  properly  called  the  Dorrance  Hook.  With  it  a 
man  can  hold  a  rope  and  support  his  weight.  It  is  not 


PROSTHETIC   APPLIANCES  137 

likely  to  get  out  of  order  and  can  be  easily  repaired  by 
the  wearer.  The  cost  is  $100.00.  For  aesthetic  reasons 
a  hand  may  be  slipped  over  the  unsightly  hooks.  This 
is  arranged  to  be  used  for  movements  requiring  little 
strength,  such  as  taking  off  the  hat,  or  handling  a  knife, 
fork,  cup  or  glass. 


FIG.  11. — Violin  player  with  Amar  arm. 

Other  utility  arms  consist  of  a  series  of  metal  clamps 
and  joints.  There  are  a  number  of  these  forms.  Those 
used  by  Dr.  Amar  are  shown  and  need  no  description. 
Similar  arms  are  used  by  the  English  and  the  Canadians. 

The  same  sort  of  socket  for  a  temporary  leg  that  has 
been  described  (see  page  126)  may  be  combined  with  a 
clamp,  hook,  or  other  attachment  to  form  a  temporary 


138 


RECONSTRUCTION   THERAPY 


utility  arm.  Referring  to  the  use  of  temporary  arms  it 
is  said:  "  In  amputation  of  a  single  arm  it  seems  prefer- 
able for  the  patient  to  first  acquire  the  greatest  possible 
facility  with  the  remaining  arm.  In  amputation  of 
both  arms,  however,  a  simple  appliance  that  can  be 
used  as  soon  as  the  stump  is  healed  is  of  great  advantage." 
Readers  of  Dickens  will  remember  that  Captain  Cuttle 


FIG.  12. — Amar  arm  used  in  typewriting. 

had  an  artificial  arm,  which  usually  bore  a  hook  in  the 
end  but  which  could  be  replaced  by  a  fork  or  other  utensil. 
This  same  form  of  arm  can  be  purchased  to-day.  The 
utensils  may  screw  into  the  socket  or  be  held  in  position 
by  a  spring  catch.  It  is  possible  to  procure  many  forms 
of  hooks  or  clamps,  knives,  forks,  and  nail  or  hand 
brushes,  specially  designed  to  use  with  the  various 
makes  of  arms.  Ingenious  cripples  have  frequently 
devised  special  attachments  for  their  own  particular 


PROSTHETIC    APPLIANCES 


FIG.  13. — Carpenter  using  the  Amar  claw. 


140 


RECONSTRUCTION    THERAPY 


uses.  Mr.  C.  N.  Underwood  has  described1  several  in- 
vented by  one  of  the  best  mechanics  of  the  Remington 
Typewriter  Company,  a  man  with  ankylosed  joints 
from  bust  to  knees,  due  to  sciatica  and  inflammatory 
rheumatism  from  which  he  has  suffered  for  thirty-seven 
years.  Previous  to  his  affliction  he  was  a  machinist 
but  since  has  learned  the  trade  of  jeweler  and  is  now  a 


FIG.  14. — Carpenter  using  the  Amar  claw. 

toolmaker.  He  works  either  sitting  or  standing.  Like 
many  of  the  crippled  he  has  devised  very  ingenious 
devices  to  aid  him  in  the  everyday  operations  of  life, 
such  as  dressing  and  undressing.  The  rigid  joints  of  his 
body  prevent  his  bending  and  he  has  therefore  devised 
tongs  for  picking  up  articles  from  the  floor,  for  drawing 
on  his  socks,  etc.  He  uses  the  point  of  his  crutch  for 
removing  his  shoes  and  socks.  His  crutches  are  unusual 

1  Journal  of  the  American  Society  of  Mechanical  Engineers,  Vol. 
xl,  p.  58,  January,  1918. 


PROSTHETIC    APPLIANCES 


141 


and  are  his  own  design.  The  one  used  on  his  right  side 
has  a  ring  on  swivels  through  which  the  arm  is  passed. 
This  enables  him  to  let  go  of  the  crossbar  or  grip  of  the 
crutch  and  work  at  the  machine  without  any  danger  of 


FIG.  15. — A  simple  hook.  Bill  Watkins  lost  his  hand  and  the  lower 
third  of  his  forearm  by  an  explosion  of  dynamite.  He  was  fitted  a 
short  time  after  with  a  work  arm  having  a  raw  hide  socket.  Gaining 
flesh  he  outgrew  this  and  did  his  work  with  a  cotton  pad  tied  over  his 
stump.  A  fellow  employee,  an  electrician,  was  using  a  Games  arm 
and  became  interested  in  Bill,  making  him  a  willow  socket,  covered 
with  leather  and  a  new  hook.  The  catch  for  holding  the  latter  was 
taken  from  the  old  artificial  arm.  The  form  of  the  hook  is  noteworthy. 

the  crutch  getting  away  from  him.  By  letting  go  of 
the  grip  and  supporting  himself  by  his  forearm  in  the 
ring,  he  can  carry  objects  which  he  could  not  otherwise 
grasp  with  his  hand  holding  the  crutch. 


142 


RECONSTRUCTION    THERAPY 


The  other  crutch  has  no  upper  crosspiece  fitting  into 
the  axilla,  but  the  supports  are  joined  as  at  the  bottom 
forming  a  point.  This  rests  against  the  outer  side  of 
the  arm  (Figs.  18  and  19). 

One  rather  ingenious  appliance  was  described  to  me 
by  a  contractor  of  West  Virginia  who  had  employed  a 


FIG.  16. — Pushing  a  lawn  mower  with  a  simple  hook. 

negro  laborer  whose  left  arm  had  been  amputated  at 
the  shoulder.  In  using  a  shovel,  it  may  be  looked  upon 
as  a  lever  with  the  hand  holding  the  shovel  midway  as 
the  fulcrum.  In  order  to  supply  this  fulcrum,  the  laborer 
used  a  surcingle,  a  broad  webbing  belt  used  to  hold 
blankets  or  saddles  on  horses,  which  was  passed  over 
the  right  shoulder  and  around  the  shovel  handle  at  the 
point  ordinarily  grasped  by  the  fulcrum  hand.  The 


PROSTHETIC   APPLIANCES 


143 


FIG.   17. — Foreign  toolholders  and  grips.     (Harper.) 


144 


RECONSTRUCTION    THERAPY 


left  foot  drove  the  shovel  into  the  ground,  the  body  was 
raised  and  the  right  hand  depressed  the  handle,  thus 
bringing  the  shovel  with  its  load  of  dirt  to  an  approx- 
imately level  position.  The  man's  right  arm  was  power- 
ful enough  to  throw  the  dirt  a  little  farther  than  the 
average  pick  and  shovel  man.  Unfortunately,  he  was 
a  periodic  drinker,  and  was  lost  sight  of  before  any 
effort  could  be  made  to  improve  his  position  in  life. 


FIG.  18. — Special  crutches.  FIG.  19. — Devices  for  dressing. 

Photos  by  F.  B.  Gilbreth. 

Fig.  20  shows  a  belt  with  an  attachment  to  hold  the 
upper  end  of  the  shovel,  the  lower  hand  acting  as  both 
power  and  fulcrum.  It  is  obvious  that  such  an  arrange- 
ment cannot  be  so  satisfactory  as  the  simpler  apparatus 
described  above.  Figs.  21  and  22  shows  French  agricul- 
turists with  double  forearm  amputations  whetting  a  scythe 
and  spading  by  means  of  simple  appliances.  Apparently 


PROSTHETIC    APPLIANCES 


145 


a  number  of  different  forms  of  hooks  and  clamps  have 
been  devised  abroad.  Several  of  these  are  shown  in 
Fig.  17. 

For  work  purposes,   the  simpler  the  apparatus  the 
more  apt  is  the  wearer  to  like  and  use  it.     It  is  also  much 


FIG. 20. — Belt  with  special  apparatus  for  shovelling,  model  Jullien. 

easier  to  repair  and  replace.  Fig.  23  shows  a  wood 
turner  who  uses  a  simple  wooden  socket,  which  can  be 
turned  from  wood,  to  hold  his  chisel,  which  he  could  very 
easily  replace  himself. 

In    the    comparatively    simple    matter    of    selecting 
10 


146  RECONSTRUCTION    THERAPY 

crutches  care  should  be  taken  to  choose  those  which  will 
not  cause  fatigue.  It  is  obvious  that  a  light,  slender 
person  can  use  a  lighter  crutch  than  a  stout  and  heavy 
individual.  Even  for  the  latter  a  light  but  strong 


FIG.  21. — Mutile  with  double  forearm  amputation  and  blind  in  right 
eye,  whetting  a  scythe  by  means  of  the  grip,  Simon,  and  toolholder, 
Lauter. 

wood  such  as  rattan  can  be  substituted  for  the  heavier 
hickory.  Then  too,  a  padded  strip  of  leather  makes 
a  more  comfortable  support  and  is  less  likely  to  cause 
crutch  palsy  than  wood,  even  though  it  be  padded. 
Some  users  of  crutches  claim  that  there  is  no  excuse 


PROSTHETIC    APPLIANCES 


147 


for  crutch  palsy,  that  the  person  using  the  crutch  should 
support  himself  with  the  hands  upon  the  grips  rather 
than  upon  the  head  of  the  crutch,  but  this  I  believe, 
is  rather  difficult  for  the  beginner  to  acquire  and  the 
tendency  is  to  rest  most  of  the  weight  upon  the  support. 


FIG.   22. — Mutile  with  double  forearm  amputation   working  with  a 
spade.     Right  arm  with  single  hook;  left  arm,  ring-hook  Aubert. 

Many  modifications  of  crutches  have  been  suggested, 
one  of  these  provides  a  swinging  support  between  the 
crutches  upon  which  the  patient  sits.  From  the  rather 
inadequate  description  given,  it  would  appear  difficult 
to  accomplish  this. 


148 


RECONSTRUCTION   THERAPY 


Another  is  a  so-called  rolling  crutch,  described  by 
Dr.  Robert  G.  Hall,1  for  which  many  advantages  are 
claimed  due  to  the  addition  of  an  arc  to  the  bottom  and  to 
extra  hand  grips  placed  in  front  of  the  usual  ones.  The 
arc  as  described  varies  from  14^  inches  to  31  inches. 
The  latter  length  can  be  folded  to  12  inches.  These 


FIG.  23. — A  French  wood  turner,  Montpelier  school,  using  simple  tool 

holder. 

crutches  have  the  disadvantage  of  weighing  69  and  74 
ounces  as  compared  to  26  ounces  for  the  old  style. 
It  is  conceivable  that  the  effort  to  manipulate  them  might 
counteract  the  fatigue  saved  by  easier  locomotion. 
It  is  also  possible  that  the  12-  or  14-inch  arc  might  prove 
gomewhat  inconvenient  when  not  in  use,  as  in  crowded 

1  Journal  of  the  American  Medical  Association,  Vol.  Ixx,  p.  666, 


PROSTHETIC    APPLIANCES 


149 


vehicles  or  halls.  From  the  list  of  their  advantages 
as  presented,  it  would  seem,  however,  that  these  crutches 
should  be  tried  before  being  condemned. 

It  is  frequently  possible  to  modify  some  implement  so 
that  it  can  be  used  by  a  cripple.  For  example,  in 
Fig.  24,  a  shows  an  old  form  of  dandelion  or  plantain 
digger  made  from  a  broomstick,  three  5-inch  wire  nails, 
and  some  fine  and  coarse  wire.  The  coarse  wire  forms 


FIG.  24. — Adaptations  of  simple  tools  for  one-armed  worker:  a, 
original  form  of  weed  puller;  b,  same  modified  for  use  of  one-armed 
worker;  c,  trowel  mounted  to  prevent  stooping. 

a  discharger  after  the  weeder  is  loaded.  6  shows  the 
same  instrument  modified  with  a  lever  which  makes 
discharging  easy  with  one  hand  so  that  it  can  be  used  by 
a  one-armed  person.  As  this  instrument  so  constructed 
makes  holes  an  inch  and  a  half  in  diameter  in  the  lawn, 
a  slim  jim  trowel  was  mounted  in  a  stick,  c,  to  fill  these 
without  stooping,  thus  eliminating  fatigue.  A  nail  or 
screw  in  the  handle  of  the  weeder  makes  it  possible  for 
the  one-armed  person  to  carry  a  basket  for  the  weeds. 


150 


RECONSTRUCTION    THERAPY 


Fig.  25  shows  a  mowing  machine  seat  modified  for  a 
driver  with  a  thigh  amputation. 

It  is  important  that  everything  possible  be  done  to 
eliminate  fatigue  for  workers.  This  has  been  preached 
for  some  time  by  the  Gilbreths.  As  they  have  shown, 
raising  or  lowering  a  chair  to  bring  the  worker  to  a  proper 
level  at  the  bench,  putting  springs  under  a  chair  to  dimin- 


FIG.  25. — Seat  of  a  mowing  machine  modified  for  a  driver  with  a  thigh 
amputation.     (Designed  by  M.  Dor.) 

ish  vibration,  providing  footrests,  arm  supports,  back 
rests,  etc.,  may  have  a  great  influence  in  reducing  fatigue. 
It  is  obviously  more  important  that  the  cripple  whose 
physical  power  is  diminished  should  have  it  conserved  in 
every  way  possible.  Study  should  therefore  be  made 
of  fatigue  eliminating  devices  and  methods. 

E.  Muirhead  Little  has   described1  what   he   calls  a 

1  Notes  on  Artificial  Limbs  for  Soldiers  and  Sailors.     American 
Journal  of  Orthopaedic  Surgery,  Vol.  xv,  p.  596,  August,  1917. 


PROSTHETIC   APPLIANCES  151 

tilting  table  for  cases  who  have  had  disarticulation 
of  the  hip-joint  and  which  "enables  a  patient  with  this 
mutilation  to  walk  better  than  one  who  has  less  than 
6  inches  of  the  femur  remaining.  The  not  very  de- 
scriptive term  of  tilting  table  is  applied  to  a  stiff  leather 
socket  which  is  accurately  moulded  upon  a  plaster  cast 
of  one-half  of  the  pelvis,  and  retained  in  position  by  a  steel 
pelvic  band  and  appropriate  straps.  To  this  a  steel 
upright  is  riveted,  which  is  jointed  at  the  site  of  the 
hip  and  continued  down  to  artificial  thigh  and  leg  pieces 
of  the  usual  kind.  The  joint  at  the  hip  is  controlled 
by  a  ring  catch  or  other  lock,  and  a  similar  lock  is  some- 
times added  to  the  kuee." 

As  has  been  said,  many  of  the  artificial  limbs  have  been 
invented  by  persons  who  were  so  unfortunate  as  to  lose 
their  natural  member,  and  who  became  dissatisfied  with 
the  limbs  on  the  market.  The  inventor  of  the  Games, 
Arm,  Mr.  William  T.  Carnes,  was  a  machinist  who  lost 
his  right  arm  2  inches  above  the  elbow.  Mr.  J.  E.  Hanger 
lost  his  leg  during  our  Civil  War.  Mr.  Lowell  E.  Jepson, 
the  inventor  of  the  double  slip  socket,  wore  an  ordinary 
single  socket  leg  for  fifteen  years  before  he  hit  upon  the 
device  to  diminish  chafing  of  the  stump.  An  especially 
notable  and  interesting  instance  is  that  of  Judge  Quentin 
D.  Corley  of  Dallas,  Texas,  whose  life  has  been  an  excellent 
example  of  pluck  and  perseverance  in  overcoming  diffi- 
culties. Early  in  life  he  showed  a  skill  in  mechanics,  but 
after  graduating  from  school  became  a  stenographer,  also 
studying  civil  engineering  during  his  spare  time.  In 
September,  1905,  while  on  his  way  to  an  eastern  college 
to  take  up  a  course  in  civil  engineering  he  was  so  unfortu- 
nate as  to  be  badly  injured  in  attempting  to  board  a 
train.  This  necessitated  the  removal  of  his  right  arm, 
shoulder-blade,  and  collar  bone,  as  well  as  his  left  hand. 
It  should  be  remembered  that  in  operating  artificial  arms, 
the  gripping  movement  of  the  hand  is  accomplished  by 
cords  going  over  the  opposite  shoulder.  As  Mr.  Corley 
had  no  right  shoulder  it  was  impossible  to  fit  such  a  hand 


152 


RECONSTRUCTION    THERAPY 


FIG,  26. — Judge  Corley  writing  with  his  special  device. 


.      PROSTHETIC    APPLIANCES  153 

to  his  left  arm.  He  has,  therefore,  evolved  a  very  ingeni- 
ous apparatus  with  which  he  can  write  very  legibly, 
folds  up  letters,  puts  them  in  envelopes,  puts  a  pen 
point  in  a  holder,  turns  leaves  of  books,  picks  up  large 
or  small  objects,  takes  money  out  of  his  pocket,  turns 


FIG.  27. — Judge  Corley  writing  with  his  artificial  hand. 

door  knobs,  carries  grips  or  other  articles,  puts  on  his 
collar  and  tie,  fastens  buttons,  bathes  himself,  combs 
his  hair,  puts  on  underclothes,  laces  shoes,  uses  tooth- 
brush, uses  knife,  fork  and  spoon  in  eating;  plants,  spades 
or  hoes  in  his  garden,  mows  lawn,  winds  up  and  plays 


154 


RECONSTRUCTION   THERAPY 


FIG.  28. — Judge  Corley  using  his  collar  and  tie  machine. 


PROSTHETIC    APPLIANCES 


155 


phonograph,  strikes  matches  and  builds  a  fire,  runs 
automobile,  bowls  ten-pins,  drives  a  horse,  swims  and 
dives.  The  above  list  is  quite  long  enough  to  prove  that 
Judge  Corley  can  do  all  that  is  required  of  a  person 
living  a  normal  life.  As  might  be  expected,  in  perform- 


FIG.  29. — Judge  Corley  using  a  special  tool  holder. 

ing  some  of  these  acts,  certain  accessory  apparatus 
is  necessary.  One  of  these  is  shown  in  the  collar  and 
tie  machine.  Also  in  hoeing  and  digging  the  appliance 
plays  but  a  slight  part,  and  any  man  with  an  elbow 
stump  and  two  legs,  possibly  both  artificial,  can  do  the 
same,  if  he  has  the  "will"  to  do  it.  The  hoe  is  picked 


156  RECONSTRUCTION   THERAPY 

up  with  the  foot,  the  handle  held  against  the  body  with 
the  arm,  and,  while  standing  on  the  left  foot,  the  right 
foot  presses  against  the  back  of  the  hoe  or  handle, 
forcing  it  into  the  ground.  Digging  is  accomplished 
in  a  similar  way,  the  right  foot  forcing  the  long  handled 
shovel  into  the  earth,  the  right  knee  being  used  as  a  ful- 
crum and  a  movement  of  the  body  throwing  the  dirt 
to  one  side. 

The  appliance  is  described  as  follows:  A  leather  cuff 
fits  the  arm  above  the  elbow  and  another  below  it.  To 
these  are  attached  side  strips  of  steel  hinged  at  the  elbow. 
The  lower  end  is  formed  of  a  flat  piece  of  steel  into  which 
is  screwed  the  appliance.  This  is  shaped  somewhat 
like  an  anchor  or  double  hook,  one  of  which  is  longer 
than  the  other.  Each  has  a  smaller  hook  on  the  end 
which  serves  many  a  useful  purpose.  Underneath  the 
hook  is  a  piece  of  spring  steel  which  holds  tight  against 
the  hooks.  This  spring  plate  is  opened  by  means  of  a 
wheel  attached  to  the  hooks,  which  is  worked  by  a  lever 
to  which  a  string  is  attached,  the  other  end  of  which  is 
attached  to  the  cuff  above  the  elbow.  When  the  elbow 
is  bent  the  lever  is  fixed  and  the  straightening  of  the  elbow 
causes  the  spring  plate  to  open  and  shut.  This  enables 
the  wearer  to  pick  up  papers,  pins,  and  anything  light. 

In  bowling  Judge  Corley  uses  a  special  apparatus 
which  works  on  the  same  principle  as  ice  tongs,  except 
that  there  are  two  prongs  on  each  side  instead  of  one. 
These  are  fastened  to  a  ring  through  which  the  forearm 
is  passed.  The  jaws  clamp  firmly  around  the  ball  and 
are  held  by  a  catch,  which  is  released  by  a  slight  move- 
ment of  the  forearm  when  the  ball  is  delivered. 

To  the  steering  wheel  of  Judge  Corley's  automobile 
is  attached  a  ring  about  6  inches  in  diameter  set  vertically 
in  a  swivel.  With  the  hook  attachment  grasping  this, 
he  steers  his  machine  well.  Cranking  is  done  with  the 
appliance  or  his  foot.  The  light  tank  is  turned  on  by 
means  of  a  square  hole  in  one  hook. 

Judge  Corley  has  invented  a  number  of  other  appli- 


PROSTHETIC   APPLIANCES 


157 


ances,  somewhat  different  from  that  described  above  for 
light  work,  one  of  which  he  calls  a  work  hook  for  use  in 
driving  a  team,  holding  a  plow,  using  a  saw,  hammer, 
spade,  or  carrying  heavy  articles.  He  also  has  a  "  hand  " 
which  is  aesthetically  an  improvement  over  his  "hook." 
Fortunately  for  those  afflicted  a  company  has  been 
formed  for  the  manufacture  of  these  articles. 


FIG.  30. — Judge  Corley  driving  his  automobile. 

In  a  periodical1  there  was  shown  a  picture  of  an 
"armless"  man  with  two  short  arm  stumps  who  drove 
an  automobile  by  means  of  a  special  steering  wheel 
in  which  the  spokes  were  replaced  by  ring's  into  which 
the  stumps  were  thrust. 

Dr.  Sutton,  one  of  our  best  billiard  experts,  is 
"armless,"  having  two  stumps  ending  just  above  the 
elbow  joint.  He  is  said  to  have  a  wonderfurdelicacy 
of  touch,  Jn  playing  he  uses  a  special  bridge  which 

1  Every  Week,  August  14,  1916, 


158  RECONSTRUCTION   THERAPY 

he  places,  then  rests  the  handle  upon  his  left  knee  which 
he  raises,  so  making  his  shots  while  standing  upon  his 
right  leg.  The  cue  is  grasped  between  the  two  stumps. 
He  first  took  up  billiard  playing  as  a  diversion  but 
developed  such  skill  that  he  has  practically  been  forced 
into  the  professional  class.  He  is  also  said  to  be  an 
expert  golf  player. 

These  are  but  few  of  many  instances  which  might  be 
cited  of  individuals  who  have  been  able  to  discount 
serious  handicaps  by  means  of  a  strong  determination 
and  a  will  to  succeed. 

If  the  crippled  patient  is  stimulated  by  accounts  of 
others  who  have  overcome  their  handicaps,  it  seems 
unquestionable,  that  he  will  make  the  greater  effort 
to  overcome  his  own  difficulties.  (Since  this  was  writ- 
ten it  has  been  stated  in  the  New  York  Times  Maga- 
zine, May  12,  1918,  that  a  wonderful  book  is  being 
compiled  in  the  Surgeon-General's  Office,  "In  which  the 
life  stories  of  maimed  and  crippled  men  who  have  over- 
come their  handicaps  are  told  in  simple  but  convincing 
fashion.")  A  collection  of  pictures  and  descriptions 
would  probably  be  helpful  for  this  purpose.  It  may 
not  be  generally  known  that  Sir  Richard  Calmady 
in  Lucas  Malet's  popular  novel  of  that  name  is  drawn 
from  Arthur  MacMorrough  Kavanagh  who  was  for 
nearly  twenty-five  years  a  member  of  the  English 
Parliament.  Although  he  was  born  with  the  merest 
rudiments  of  arms  and  legs,  he  could  fish,  shoot,  draw, 
paint,  and  write.  He  rode  to  hounds  in  a  specially 
constructed  saddle,  guiding  his  horse,  with  the  reins 
wound  around  his  rudimentary  arms.  He  was  active 
in  his  community  in  many  ways,  besides  in  the  broader 
field  of  Parliament.  A  perusal  of  the  book,  Richard 
Calmady,  might  perhaps  inspire  others  less  seriously 
handicapped. 

Many  individuals  with  one  natural  arm  prefer  to  go 
through  life  without  any  assistance  from  an  artificial 
limb,  This  is.  especially  the  case  where  the  stump  is 


PROSTHETIC    APPLIANCES  159 

of  elbow  length  or  longer,  yet  I  have  seen  persons  with 
a  shoulder  amputation  who  did  not  wish  "to  be  bothered" 
with  an  artificial  member.  It  should  be  understood 
that  it  is  difficult  to  fit  an  artificial  arm  which  will  give 
much  motion  unless  there  is  a  5-inch  stump,  so  that 
those  with  shoulder  amputation  may  feel  that  the  arti- 
ficial arm  may  be  merely  a  more  or  less  useless  ornament. 

One  is  often  surprised  at  observing  the  ease  with  which 
a  one-armed  person  does  things  which  we  with  two  do  not 
do  particularly  well,  such  as  bundle  wrapping,  or  needle- 
work. Without  doubt  it  is  possible  to  learn  to  do  many 
things  well  with  one  hand,  even  the  left,  when  patiently 
and  persistently  practised  under  intelligent  direction. 
The  great  problem,  therefore,  is  not  the  one-armed  cripple 
but  the  cripple  without  arms,  and  it  is  this  problem 
which  is  occupying  the  attention  of  the  Surgeon- 
General's  laboratory.  It  has  gotten  in  touch  with  a 
number  of  "armless''  men  who  are  giving  demonstra- 
tions of  their  ability  to  do  things.  They  are  also  being 
subjected  to  various  tests. 

Treatment  of  the  Stump. — After  an  amputation  it  is 
necessary  that  the  stump  have  certain  treatment  before 
an  artificial  limb  be  fitted  to  it.  After  healing,  the 
stump  is  bandaged  snugly  from  the  end  to  the  next  joint. 
This  bandage  should  be  taken  off  night  and  morning, 
the  stump  bathed  with  cold  water,  well  massaged,  and 
the  bandage  replaced  snugly.  If  the  skin  is  tender 
the  stump  should  be  bathed  with  alcohol  or  a  solution 
of  tannic  acid.  Usually  about  two  weeks  of  such  treat- 
ment is  required  to  "harden''  the  stump,  and  prevent 
the  accumulation  of  fat.  -Needless  to  say,  the  stump 
should  always  be  exercised  as  much  as  possible. 

The  Surgeon-General's  Office  has  authorized  the  pub- 
lication of  certain  directions  as  to  the  fitting  of  arti- 
ficial limbs1  in  which  somewhat  fuller  directions  are 
given  for  treatment  of  the  stump  than  those  above. 

1  The  Relation  Between  the  Amputation  and  the  Fitting  of  the 
Artificial  Limb.  Military  Surgeon,  xlii,  154,  February,  1918. 


160  RECONSTRUCTION    THERAPY 

As  soon  as  the  wound  is  healed,  and  while  the  patient 
is  still  confined  to  bed,  the  stump  is  massaged,  care  being 
taken  to  avoid  re-opening  the  wound.  The  stump  is  also 
carefully  bandaged.  For  several  minutes  duration  at 
four- or  five-hour  intervals  the  patient  takes  pressure  exer- 
cises, the  end  of  the  stump  being  pressed  upon  a  cushion 
or  the  edge  of  the  bed,  so  that  it  will  gradually  become 
hardened  or  accustomed  to  the  strains  which  will  be  put 
upon  it.  Next,  active  movements  in  all  directions  are 
practised,  with  the  special  object  of  keeping  up  the 
muscle  strength.  Later,  to  these  same  general  move- 
ments resistance  is  added.  Baths  are  carried  on  through- 
out the  treatment. 

According  to  E.  Muirhead  Little  (op.  cit.)  few  stumps 
are  fit  for  appliances  until  six  months  after  amputation. 

Most  wonderful  aesthetic  effects  have  been  devised 
to  overcome  deformities  of  the  face  especially  due  to 
mutilation  from  wounds.  Perhaps  the  greatest  meed  of 
praise*  should  be  given  to  the  dentists  who  have  achieved 
literally  wonderful  results,  but  it  should  not  be  forgotten 
that  the  surgeons  have  also  done  most  ingenious  plastic 
work.  A  Frenchman  has  invented  a  rubber  composition 
to  build  up  missing  noses  or  fill  out  hollows,  which  is 
tinted  flesh  color  and  is  applied  like  a  paste.  An  arti- 
ficial nose  may  be  made  of  thin  metal,  flesh  tinted,  and 
held  in  position  by  spectacles. 

An  English  sculptor,  Derwent  Wood,  A.  R.  A.,  has 
developed  this  work  to  such  an  extent  that  he  has  been 
placed  in  charge  of  the  Masks  for  Facial  Disfigurements 
Department  in  the  British  General  Service.  By  his 
painstaking  carefulness  and  attention  to  detail,  he  has 
achieved  splendid  results,  according  to  Mr.  Ward  Muir 
who  has  described  the  sculptor's  work.1  When  pos- 
sible the  subject  supplies  a  picture  of  himself  before 
his  injury.  A  cast  is  taken  of  his  face  in  its  present 
mutilated  condition,  which  is  built  up  to  correspond 
with  the  portrait.  By  electrolysis  a  thin  copper  mask 
1  Nineteenth  Century  Magazine,  October,  1917. 


PROSTHETIC    APPLIANCES  161 

is  made  on  this  built  up  cast  and  is  then  fitted  carefully 
to  the  deformed  face.  When  this  has  been  done, 
the  mask  is  silver  plated  and  then  artistically  tinted  so 
that  at  a  short  distance  it  is  impossible  to  distinguish 
between  the  mask  and  the  skin  of  the  wearer. 

Another  artist  who  has  done  interesting  and  valuable 
work  is  Miss  Grace  Cassette,  an  American  who  has  re- 
sided in  Paris  for  twenty  years.  She  has  shown  great 
ingenuity  in  devising  special  splints  and  corrective 
appliances  for  use  in  the  French  Hospitals.  Her  work 
has  been  interestingly  described  in  The  Modern  Hospital, 
Vol.  ix,  p.  92,  August,  1917. 

It  should  be  distinctly  understood  that  mention  has 
been  made  of  but  few  of  the  many  prosthetic  appliances 
which  are  known  at  the  present  time.  While  it  might 
be  well  to  discuss  others  and  also  the  simpler  forms  of 
labor-saving  devices,  to  do  justice  to  the  subject  would 
require  a  large  volume.  Labor-saving  devices  are  im- 
portant and  should  be  better  known,  for  by  their  use 
it  is  probable  that  both  physical  and  mental  strain  might 
be  avoided.  It  is  unfortunate  that  at  present  there  is 
no  governmental  department  which  is  in  a  position  to 
give  informaton  regarding  these  matters.  Possibly  in 
the  near  future  a  department  will  be  organized  which  will 
collect  the  knowledge,  at  present  scattered  and  avail- 
able only  with  more  or  less  difficulty  in  the  Patent  Office, 
Surgeon-General's  Office,  American  Museum  of  Safety, 
and  among  private  individuals,  so  that  it  may  be  better 
disseminated. 


11 


CHAPTER  XII 
PHYSICAL  EDUCATION 

Right  living,  that  is  normal  living,  includes  much 
more  physical  activity  than  exists  in  the  life  of  most 
people.  It  is  important  that  our  patients  be  taught 
this  fact  and  that  they  be  instructed  in  those  exercises 
which  are  best  for  them.  It  is  also  necessary  that  our 
nurses  be  taught  how  to  give  them. 

The  manner  of  such  exercises  may  be  greatly  varied. 
Too  frequently,  perhaps,  we  feel  that  in  calisthenics  we 
have  the  one  essential.  It  is  true  that  such  exercises 
are  very  important  and  a  knowledge  of  them  should 
be  imparted  to  all  of  our  pupil  nurses.  Frequently 
a  sedentary  worker  can  keep  himself  in  a  condition 
that  is  fairly  "fit''  by  the  regular  use  of  a  few  calisthenic 
exercises  even  for  a  very  small  portion  of  his  working 
day.  The  great  disadvantage  of  these  formal  exercises 
is  that  they  are  apt  to  be  uninteresting  and  especially 
so  when  carried  out  alone.  The  addition  of  music  will 
do  much  to  increase  the  interest,  even  to  the  solitary 
exerciser  who  works  with  a  victrola,  and  will  also  do 
much  to  train  in  co-ordination.  Marches  and  drills, 
when  the  numbers  will  permit,  may  be  made  quite 
attractive.  Folk  dancing  should  prove  of  value,  despite 
the  greater  effort  required  to  learn  it,  and  if  possible 
should  be  taught  to  the  convalescent  patients  and  to  the 
nurses,  if  only  as  a  diversion. 

Eurythmic  dancing  is  theoretically  an  ideal  exercise, 
but  can  probably  be  used  in  only  a  small  number  of 
cases,  so  that  it  seems  hardly  worth  while  to  attempt 
it  with  our  patients  or  nurses.  This  is  especially  true 
since  its  exponents  claim  that  four  or  five  years  are  re- 

162 


PHYSICAL    EDUCATION  163 

quired  to  learn  it.  Probably  this  is  necessary  for  those 
becoming  professionals,  but  the  beneficial  effects  may 
be  derived  without  taking  it  up  so  seriously.  It  would 
be  well  to  give  a  demonstration  of  this  form  of  ex- 
ercise, or  at  least  a  talk  on  the  subject  illustrated  by 
pictures,  if  modesty  deters  the  director  or  assistants  from 
performing. 

It  frequently  happens  that  an  individual  is  introduced 
to  physical  exercises  too  strenuously  and  as  a  consequence 
acquires  a  distaste  for  them.  I  believe  a  period  of  five 
minutes  is  long  enough  until  the  subject's  muscles 
begin  to  show  the  good  effects.  A  better  plan  probably 
is  to  stop  a  movement  just  as  soon  as  the  muscles  feel 
slight  signs  of  fatigue  and  change  to  one  using  a  different 
set. 

Games  of  various  sorts  are  usually  much  more  interest- 
ing and  the  physical  effect  is  better.  The  element  of 
competition  does  much  to  add  "spice"  to  physical  ex- 
ercises. The  number  of  these  is  large,  from  baseball 
down  to  tag  or  prisoner's  base.  Indoor  baseball  or 
playground  ball  are  excellent  both  for  men  or  women. 
It  is  well  to  have  some  instruction  given  to  both  nurses 
and  patients  in  whatever  games  are  utilized  in  the  insti- 
tution for  the  patients'  health  or  diversion.  They  will 
be  done  better  if  done  understandingly.  Even  billiards 
or  pool,  or  bagatelle  may  be  looked  upon  as  provid- 
ing slight  physical  exercise.  The  following  list  may  be 
suggestive : 


Tag,  Prisoner's  base,  Puss  in  corner, 

Duck  on  Davy,  Playground  ball,         Monkey  ball, 

Indoor  baseball,  Dodge  ball, 

Playground  games   (see  M.   Hofer  for  list  and  directions  of  a 

number), 

Croquet,  Dancing, 

Tennis, 
Cricket, 
Baseball, 


164  RECONSTRUCTION    THERAPY 

It  is  very  important  that  some  instruction  be  given  to  the 
nurses  regarding  the  general  and  local  effects  of  all  games 
or  other  forms  of  physical  exercise.  This  is  especially 
the  case  at  present  when  active  preparations  are  being 
made  to  care  for  those  disabled  by  the  great  war. 

Restoration  of  function  can  be  better  established  by 
means  of  games  which  arouse  the  interest  of  the  patient 
than  by  formal  exercise.  It  is  usually  necessary  to  have 
a  preparatory  period  of  massage  and  passive  movements 
before  active  movements  can  be  attempted,  but  after  this, 
games  and  work  at  some  of  the  crafts  will  cause  a  more 
rapid  restoration  of  function  following  a  fracture  or 
paralysis  than  if  the  former  only  is  persisted  in. 

In  an  interesting  sketch  of  Sir  William  Robertson, 
late  Chief  of  the  British  Imperial  General  Staff  at  White- 
hall, occurs  the  following:  The  physical  training  of  the 
period  in  the  British  Army  was  ridiculously  acrobatic. 
The  man  in  the  ranks  would  be  put  through  all  kinds  of 
movements  which  were  absolutely  useless  from  the  stand- 
point of  actual  battle.  The  strain  seemed  altogether 
absurd  to  Robertson.  He  ventured  to  point  this  out 
in  an  examination  paper.  "That  exercise,"  retorted 
the  medical  officer  in  the  course  of  a  subsequent  discus- 
sion with  the  non-coms,  "strengthens  the  muscles 
needed  for  climbing."  "Why  not  climb  then?"  asked 
Robertson.  (Current  Opinion  for  April,  1917,  p.  247. 
The  Soldier  Who  Rose  from  the  Ranks  to  be  the  Brains 
of  the  British  Army.) 

The  keen  mind  of  General  Robertson  went  directly 
to  the  root  of  the  matter  without  wandering  about  in 
a  pseudo-scientific  morass  before  coming  to  a  natural 
conclusion.  Undoubtedly  the  work  as  planned  by  him 
was  more  interesting  than  when  given  as  set  exercises. 
Unfortunately,  in  the  past  the  director  of  physical  exer- 
cises has  lost  sight  of  this  very  important  factor  and  has 
consequently  not  obtained  the  best  results  from  his  work. 
Who  can  name  one  or  more  acquaintances  who  regularly 
year  after  year  have  been  members  of  a  class  of  physical 


PHYSICAL   EDUCATION  165 

education?  Fortunately,  the  desirability  of  creating 
interest  has  been  recognized  and  has  been  introduced  in 
the  form  of  competition.  This  is  a  cardinal  principle 
in  all  playground  games,  and  has  also  been  extended 
to  gymnasium  work. 

It  is  for  this  reason,  the  lack  of  interest,  that  I  have 
always  been  prejudiced  against  Zander  apparatus. 
While  they  are  undoubtedly  valuable  when  passive 
movement  is  required,  their  devotees  carry  their  use 
too  far,  and  at  best  the  majority  of  the  different  forms 
are  poor  substitutes  for  something  better.  In  the 
physical  training  or  re-education  of  the  crippled,  however, 
it  is  frequently  necessary  to  start  the  refunctioning  of 
a  limb,  with  the  Zander  or  other  apparatus.  Numerous 
ingenious  forms  have  been  devised1  but  we  frequently 
find  many  adaptations  of  things  in  common  use,  such 
as  a  bicycle,  replacing  these  special  forms  of  apparatus. 
Dr.  R.  Fortescue  Fox  (1.  c.,  p.  194)  says:  "When 
the  disabled  limb  and  the  will  are  brought  to  the  point 
of  being  able  to  do  something,  the  last  stage  of  treatment 
has  been  reached"  (p.  195).  "It  will  be  found  to  be  of 
great  practical  importance  that  the  nature  of  an  occupa- 
tion should  be  precisely  adjusted  to  the  individual 
condition  of  each  man's  natural  bent  as  well  as  his 
skill  and  experience  in  his  previous  occupation. 

"Some  common  experiences  at  the  Red  Cross  Physical 
Clinic  in  London  may  serve  to  illustrate  the  place  that 
work  may,  and  indeed,  at  the  proper  moment  must, 
occupy  in  the  process  of  treatment.  An  officer  whose 
femur  had  been  fractured  came  under  treatment  by 
baths,  massage  and  mechanical  exercises  for  stiffness 
of  the  knee  and  wasting  of  the  associated  extensor 

1  For  a  description  of  a  number  of  these,  see  Physical  Remedies 
for  Disabled  Soldiers,  by  R.  Fortescue  Fox,  M.  D.,  N.  Y.,  1917, 
Wm.  Wood  and  Company.  Mechanotherapy,  by  Dr.  Armand 
Deltenre.  Special  Bulletin,  Canadian  Military  Hospitals  Com- 
mission, April,  1916,  p.  55,  et  seq.  .  .  .  Reclaiming  the  Maimed, 
by  R.  Tait  McKenzie,  M.  D.  N.  Y.,  1918,  Macmillan  Co. 


166  RECONSTRUCTION   THERAPY 

muscles.  In  two  months  the  movement  and  muscular 
power  were  much  increased,  but  the  limit  of  benefit 
appeared  to  have  been  reached.  When  he  returned 
home  and  began  rough  walking  over  his  property  in 
Scotland,  the  limb  was  still  further  improved.  Another 
officer,  after  a  course  of  treatment  for  a  stiff  knee,  found 
great  benefit  from  working  with  a  scythe;  and  a  third, 
recovering  from  immobility  of  the  shoulder-joint  fol- 
lowing fracture  near  the  head  of  the  humerus,  from 
daily  sawing  of  logs  of  wood."  The  value  of  mental 
co-operation  in  physical  re-education  cannot  be  too 
strongly  insisted  upon  and  the  work  of  Dr.  W.  J.  M.  A. 
Maloney,  of  Dr.  H.  S.  Frenkel,  and  of  Dr.  Shepherd 
Ivory  Franz  gives  ample  proof  of  this. 

In  his  paper  on  The  Cure  of  Ataxia1  Dr.  W.  J.  M.  A. 
Maloney  enunciates  some  principles  for  the  amelioration 
of  tabetic  ataxia  which  should  prove  of  value  in  the  treat- 
ment of  all  forms  of  paralysis  and  in  the  re-education 
of  movement  following  fractures  or  other  injuries. 
The  first  step  is  to  eliminate  fear  and  this  is  aided  by  the 
use  of  simple  mechanical  measures.  A  high  shoe  or 
boot  with  special  ankle  support  and  other  features2 
has  been  found  of  value.  The  knees  may  also  be  given 
support  by  bandaging  with  light  webbing. 

At  the  treatments,  which  are  given  every  other  day 
and  last  from  a  half  to  one  hour,  the  patient  is  made  to 
lie  down,  blindfolded.  "  He  is  (pp.  1047  to  1048)  enjoined 
to  dismiss  all  thoughts  of  extraneous  affairs,  to  allow 
his  mind  to  tranquilize,  and  to  attend  strictly  to  what 
he  is  told.  The  room  is  maintained  as  quiet  as  possible 
to  avoid  distracting  him.  He  is  then  ordered  to  relax 
the  muscles  first  of  his  face,  then  of  his  neck,  then  of 
his  trunk  and  then  of  his  limbs.  Each  order  is  repeated 

1  New  York  Medical  Journal,  Vol.  xcviii,  p.  1045,  November  29, 
1913. 

2  Maloney   and   Sorapure.     The    Mechanical   Support   of   the 
Feet  in  Locomotor  Ataxia.     Medical  Record,  Vol.  Ixxxv,  p.  881, 
May  16,  1914. 


PHYSICAL    EDUCATION  167 

and  restated,  first  alone,  and  then  linked  with  the  pre- 
ceding order.  The  whole  process  is  conducted  slowly 
and  with  suitable  pauses.  From  these  relaxation 
exercises,  practised  blindfolded,  three  results  are  attained ; 
first,  ineffective,  often  useless,  and  sometimes  completely 
disconcerting  muscular  contractions  which  have  been 
acquired  in  attempts  to  balance,  are  got  rid  of  so  that  the 
co-ordinating  exercises  can  be  begun  on  an  unconstrained 
musculature  and  not  superimposed  upon  existing  habit 
contractions.  Secondly,  active  relaxation  confers  a 
great  training  in  attending  to  muscular  sense  impressions. 
Thirdly,  the  patient  becomes  less  fearful  and  more 
receptive  because,  in  so  far  as  fear  is  maintained  by  its 
motor  expressions  in  his  attitude,  it  is  diminished. 
Patients  report  spontaneously  that  these  blindfolded 
relaxation  exercises  greatly  improve  their  sleeping  power. 
They  tend  to  sleep  excessively.  Arrears  of  sleep  are 
made  up  and  pains  often  disappear  under  the  improved 
mental  condition  which  now  ensues. 

"  After  general  relaxation  has  been  practised,  attention 
is  specially  directed  to  one  region,  say  the  right  lower  limb. 
Relaxation  of  the  ankle,  knee,  and  hip  muscles  is  then 
insisted  upon.  First  each  is  separately  considered, 
then  reconsidered,  and  finally  all  are  linked  together 
so  that  as  great  a  degree  of  muscular  relaxation  as 
possible  is  obtained  in  the  chosen  limb. 

Movements. — "  Next  movements  are  begun.  Passive 
flexion  and  extension  of  the  ankle  is  first  practised. 
The  foot  is  placed  in  extreme  flexion,  and  the  patient 
is  instructed  to  count  slowly  while  the  physician  at  a 
uniform  rate  moves  the  foot  to  a  position  of  complete 
extension,  pauses,  and  then  returns  the  foot  to  complete 
flexion.  The  purpose  of  the  passive  movements  is  to 
teach  the  correct  direction  and  extent  of  each  movement. 
Next  the  patient  lightly  but  steadily  resists  the  passive 
movement.  Then  the  movement  is  practised  with  the 
patient  performing  and  the  physician  aiding  and  guiding. 
The  physician's  aid  gradually  lessens  as  improvement 


168  RECONSTRUCTION    THERAPY 

occurs.  And  then  the  movement  is  executed  by  the 
patient  alone.  Finally,  the  movement  is  made  against 
resistance.  It  is  essential  that  the  movement  should 
always  be  completed  by  the  return  of  the  limb  to  the 
position  from  which  the  movement  started.  During 
every  movement  the  patient  counts  rhythmically.  The 
purpose  of  the  counting  is  to  educate  the  patient  to 
move  easily  and  uniformly,  at  a  regular  tempo.  After 
the  ankle,  first  the  knee  and  then  the  hip  of  the  same  limb 
are  educated.  Besides  flexion  and  extension,  all  the 
simple  movements  which  can  take  place  at  the  joint 
are  practised.  All  exercises  are  done  without  shoes; 
artificial  aids  should  not  be  employed  during  the  ex- 
ercises. In  every  case,  first  relaxation,  next  passive, 
then  passive  resisted,  then  passive  combined  with  active, 
then  active  unaided,  and  finally  active  resisted  move- 
ments are  practised.  When  the  ankle  movements  have 
been  acquired  then  movement  exercises  are  begun  with 
knee  movements;  when  knee  movements  have  also  been 
acquired  then  ankle  and  knee  movements  are  repeated 
before  each  attempt  at  the  hip  movements;  and  so  forth. 
The  repetition,  after  relaxation  exercises,  of  a  movement 
which  can  be  proficiently  performed  is  a  great  aid  in 
the  learning  of  the  next  new  movement. 

"The  limb  movements  which  are  practised  in  the 
recumbent  posture  may  also,  if  possible,  be  practised, 
as  occasion  permits,  in  the  sitting  posture. 

"Before  any  attempt  is  made  to  teach  progression  the 
trunk  muscles  must  first  be  co-ordinated  by  relaxation 
and  movement.  This  is  usually  easy  for,  the  upper  limbs 
being  seldom  ataxic,  may  be  used  to  practise  lateral 
and  forward  thrusts,  elevation  to  the  sitting  and  re- 
sumption of  the  recumbent  posture,  with  aid  and  against 
resistance. 

"The  head  and  neck  muscles  are  similarly  treated. 
Their  treatment  is  just  as  important  as  that  of  any  other 
part.  The  position  of  the  head  largely  governs  the 
attitude  of  the  body. 


PHYSICAL   EDUCATION  169 

"Too  great  stress  cannot  be  laid  on  this  preliminary 
training  in  attitude.  What  may  be  called  static  co- 
ordination is  a  vital  essential  to  correct  progression. 
We  know  from  the  experiments  of  Vierordt  and  others 
that  all  local  movements  are  but  maximum  expressions 
of  a  general  muscular  change.  The  general  muscular 
change  must  not  be  neglected  in  favor  of  the  local 
movement.  Co-ordinate  movement  of  the  lower  limbs 
can  produce  only  a  travesty  of  walking  if  the  trunk 
and  head  are  wabbly.  The  whole  body  must  be  taught 
to  move  harmoniously.  The  first  essential  of  stability 
in  walking  is  stability  at  rest. 

"After  the  exercises  in  the  recumbent  and  sitting 
postures  have  been  completed  the  first  attempt  at 
progression  is  made.  Kneecaps  similar  to  those  used 
by  carpenters,  but  well  padded,  are  tied  on  the  knees 
and  the  patient  is  instructed  in  creeping.  The  change 
from  the  recumbent  to  the  creeping  posture  does  not 
unduly  strain  the  patient's  confidence  in  his  powers  of 
unaided  blindfold  progression.  The  creeping  move- 
ments are  conducted  with  the  back  as  horizontal  as 
possible;  squatting  must  not  be  permitted.  The  tempo 
of  the  movement  is  again  carefully  regulated  by  counting. 
The  direction  is  insured  by  means  of  a  strip  of  carpet 
or  linoleum  upon  which  the  creeping  is  performed. 

"After  creeping  has  been  practised  for  some  time,  first, 
changing  from  the  creeping  posture  to  kneeling  up, 
and  then,  rising  from  the  sitting  posture  to  the  upright 
are  attempted. 

"In  the  erect  kneeling  posture  progression  is  practised. 
Progression  in  the  creeping  and  erect  kneeling  postures 
trains  a  person  to  move  his. body  automatically  with 
his  lower  limbs.  This  training  is  invaluable  as  an  aid  to 
walking.  The  dire  dilemmas,  which  to  move  first, 
the  body  or  the  leg,  how  much  to  move  the  one  without 
the  other  are  obviated,  and  the  transition  from  standing 
to  walking  occurs  almost  imperceptibly. 

"Finally  walking  is  taught.     To  maintain   direction 


170  RECONSTRUCTION    THERAPY 

during  blindfold  walking,  strips  of  carpet  or  linoleum 
are  again  used.  These  strips  should  be  arranged  paralled 
with  the  walls  of  the  room  so  that  the  patient  may  at 
first  "feel''  his  way.  As  proficiency  increases  the  patient 
passes  from  a  40-inch  width  of  carpet  or  lineoleum  to  30-, 
20-,  15-,  and  even  10-  and  5-inch  widths." 

Dr.  Maloney  believes  that  the  removal  of  the  ataxia 
is  the  best  treatment  of  fear,  but  finds  it  valuable  to 
explain  to  the  patient  the  origin  of  his  fears.  Deep 
breathing  has  also  been  proved  to  aid  in  controlling 
fear. 

Dr.  Maloney  found  that  the  exercises  which  he  gave 
to  tabetics  had  the  effect  of  lowering  the  blood  pressure; 
and  observed  the  same  result  in  a  case  of  nephritis. 
With  Dr.  Sorapure  and  others  it  was  established  that 
by  the  use  of  breathing  and  relaxing  exercises  it  was 
possible  to  lower  the  blood  pressure  from  over  200  to  from 
165  to  190,  which  in  certain  cases  might  be  of  consider- 
able benefit.  A  perusal  of  their  paper1  is  desirable,  but 
the  directions  for  giving  these  exercises  are  as  follows : 

"Breathing  Exercises. — As  we  seldom  use  effort  to 
expire,  and  often  need  effort  to  inspire,  expiration, 
throughout  life,  is  to  a  great  extent  a  passive,  mechanical 
art;  whereas  inspiration  more  often  is  consciously  per- 
formed. So  inspiration  is  usually  better  controlled  than 
expiration,  and  much  of  the  trouble  in  teaching  breath- 
ing exercises  lies  in  training  patients  to  govern  their  ex- 
piration. We  first  instruct  the  patient  to  breathe  deeply, 
and  to  pause  at  the  end  both  of  inspiration  and  of  expira- 
tion. The  breathing  should  be  abdominal  and  should  be 
done  without  jerking.  One  of  the  purposes  of  deep 
breathing  is  to  distract  the  patient  from  obsessing  thoughts 
and  disturbing  ideas,  to  focus  his  attention  upon  the 
exercises.  But  deep  breathing  quickly  tires  patients. 
Therefore,  after  about  twelve  full  breaths,  the  patient 

1  The  Relief  of  States  of  High  Vascular,  Muscular,  and  Mental 
Tension.  New  York  Medical  Journal,  Vol.  xclx,  p.  1021,  May  23, 
1914. 


PHYSICAL   EDUCATION  171 

is  allowed  to  pass  to  breathing  of  moderate  amplitude. 
Now  all  imagery  is  discouraged.  The  patient  is  asked 
to  feel  only  the  passage  of  the  air  through  his  nasal 
cavities,  only  the  tactile  sensations  which  arise  from 
the  movements  of  his  abdominal  wall  against  his  clothes. 
While  he  is  so  practising,  he  is  cautioned  to  stop  any 
distracting  thoughts  as  they  arise,  to  keep  his  attention 
upon  the  sensations  which  accompany  his  breathing. 
Aiter  a  few  minutes  of  "medium"  breathing,  the  patient 
is  taught  to  breathe  gently  and  quietly  and  to  attend 
only  to  the  accompanying  sensations.  A  bag  of  sand 
or  shot,  or  other  heavy  object,  placed  upon  the  abdomen, 
is  useful  to  increase  the  muscular  effort  involved  in 
breathing,  so  that  breathing,  during  the  exercise,  may 
not  easily  lapse  into  an  unconscious  act.  Instead  of 
the  sand  bag,  the  physician's  hand  may  be  used. 

"Relaxation  Exercises. — To  relax  the  muscles,  passive 
movements  in  which  the  muscles  are  alternately 
lengthened  and  shortened,  are  employed.  The  scalp, 
forehead,  cheek,  and  jaw  muscles  of  the  recumbent 
patient  are  passively  moved  by  the  physician,  till 
wrinkling  diminishes  or  disappears  and  muscular  spasm 
is  eliminated.  Next,  a  shoulder  is  relaxed;  then  an 
arm.  Each  limb  is  dealt  with  separately.  Each  joint 
is  passively  moved  until  all  trace  of  muscular  tension 
vanishes.  When  the  joints  of  a  part  are  free  from  all 
muscular  constraint,  the  part  lies  motionless  or  flaccid 
or  falls  limply  from  any  unsupported  position.  After  a 
part  is  relaxed  those  previously,  and  those  newly  re- 
laxed should  be  briefly  dealt  with  again,  and  in  the  order 
in  which  they  were  first  relaxed.  Thus,  after  relaxing 
the  first  limb,  the  physician  turns  again  to  the  scalp, 
forehead,  cheeks,  and  jaw;  relaxes  those,  and  then  again 
the  limb.  This  linking  of  parts  previously,  to  parts 
newly  relaxed  is  helpful  in  bringing  the  whole  to  a 
satisfactory  state  of  relaxation. 

"The  relaxation  of  the  neck  and  trunk  muscles  is 
best  accomplished  while  the  patient  sits.  The  patient's 


172  RECONSTRUCTION    THERAPY 

relaxed  arms  should  then  hang  loosely  down  by  his  side, 
and  his  feet,  crossed  one  over  the  other,  should  rest  on 
their  outer  borders.  The  head  should  next  be  passively 
rotated  in  all  directions,  slowly  and  repeatedly.  Then, 
by  moving  the  supported  trunk,  the  head  is  allowed  to 
fall  passively  backward  and  forward,  by  its  own  weight. 
Finally,  the  head  rests  with  the  chin  upon  the  chest, 
or  hangs  forward  suspended  by  the  ligamentum  nuchse. 

"The  trunk  should  be  slowly  bent  backward  and 
forward  and  from  side  to  side,  until  sufficient  loosening 
of  the  muscles  is  obtained  to  allow  the  trunk  to  gravitate 
without  restraint  in  whatever  direction  it  is  inclined, 
unsupported. 

"All  movements  should  be  first  passively  made  by  the 
physician,  and  then,  where  possible — limbs,  head  and 
trunk — passively  induced  by  the  action  of  gravity." 

Dr.  Franz  and  his  associates,  Dr.  Mildred  E.  Schutz 
and  Dr.  Anita  A.  Wilson,  undertook  an  investigation  of 
"The  Possibility  of  the  Recovery  of  Motor  Function 
in  Long-standing  Hemiplegia."1  The  results  achieved 
have  been  very  encouraging  and  show  how  much  can 
be  accomplished  by  intelligent  effort.  It  is  first  deter- 
mined just  what  muscles  are  affected,  that  is,  what  are  the 
"secondary  results."  "The  limb  which  at  first  was 
flaccid  may  become  flexed  (in  the  case  of  the  arm)  or 
overextended  (as  happens  with  the  leg).  In  the  arm 
segment,  for  example,  the  fingers  are  flexed,  the  wrist  is 
flexed  and  pronated,  there  is  flexion  at  the  elbow,  and 
the  arm  is  adducted  at  the  shoulder-joint.  These 
constant  flexions  result  in  contractures,  with  limitations 
of  the  possible  passive  movements  at  the  joints,  and 
the  contractures  are  a  deformity."  In  treating  these 
cases,  "three  general  methods  were  employed.  The 
first  was  that  of  massage  and  vibration.  For  the  muscles 
which  were  strongly  contracted  effleurage,  or  stroking, 
was  employed.  The  contracted  muscles  were  stroked  in 

1 A  Preliminary  Report.  Journal  of  the  American  Medical 
Association,  Vol.  Ixv,  pp.  2150-2155,  December  18,  1915. 


PHYSICAL    EDUCATION  173 

order  to  reduce  the  hypertonicity,  if  possible.  For  the 
same  reason,  the  hand  was  grasped  and  the  arm  shaken 
or  vibrated  until  there  had  been  a  distinct  loosening 
of  the  muscles.  The  extensors  were  also  percussed 
(tapotement)  to  give  them  the  benefit  of  the  mechanical 
stimulation,  and  the  nerves  of  the  arm  were  also  stimu- 
lated by  deep  pressure."  Dr.  Franz  condemns  the 
use  of  indiscriminate  massage  and  limits  its  use  to  the 
contracted  muscles. 

All  kinds  of  movements  of  the  arms  were  also  produced 
passively,  when  possible,  special  attention  being  given 
to  extensions  on  account  of  the  continued  flexions. 
It  was  not  found  possible  to  pronate  or  supinate  the  arm 
[this  experimental  work  was  limited  to  the  arm  in 
this  series]  in  some  cases  at  first,  and  the  amount  of 
passive  extension  was  limited  during  the  early  treat- 
ments. In  some  cases  much  pain  was  experienced  in 
these  procedures. 

"The  first  two  methods  were  employed  in  order  to 
make  possible  the  third,  which  was  that  of  trying  to 
get  the  patients  to  use  voluntarily  the  extensor  muscles 
in  some  simple  'activities.  In  some  cases  voluntary 
movements  on  the  part  of  the  patients  could  not  be  ob- 
tained for  some  weeks,  but  in  all  cases  these  were  even- 
tually obtained." 

The  " simple  activities"  included  throwing  a  tennis 
ball  into  a  waste  basket  set  by  a  wall  6  feet  away  from  the 
patient,  opening  the  fingers  after  a  ball  had  been  placed 
in  the  hand,  drawing  lines  with  a  pencil,  the  patient 
touching  indicated  squares  on  a  "piano''  board,  and  sew- 
ing. It  is  noteworthy  that  like  Frenkel  and  Maloney, 
Dr.  Franz  enlists  the  will  and  interest  of  the  patient. 

The  exercises  as  laid  down  by  H.  S.  Frenkel1  while 
open  to  the  objection  of  being  uninteresting  must  be 
considered  a  step  in  advance  of  passive  movements. 
They  are  not  entirely  lacking  in  interest,  however,  as 

1  The  Treatment  of  Tabetic  Ataxia  by  Means  of  Systematic 
Exercise.  Philadelphia,  1902,  P.  Blakiston's  Son  &  Co. 


174  RECONSTRUCTION   THERAPY 

it  is  always  possible  for  the  patient  to  do  a  little  better, 
just  as  in  golf  we  are  always  striving  to  beat  Colonel 
Bogie. 

For  re-education  in  walking  and  other  co-ordinated 
movements  these  exercises  are  excellent  and  may  be 
given  with  benefit  to  many  of  our  patients.  Besides 
tabetics,  undoubtedly  the  crippled  learning  to  use  arti- 
ficial limbs,  hysterics,  and  others  can  be  helped  by  them. 
The  apparatus  required  is  slight,  and  many  of  the  exer- 
cises can  be  often  adapted  to  common  implements 
in  daily  use.  At  least  some  slight  instruction  in  these 
exercises  should  be  given  to  nurses  who  are  to  care  for 
nervous  cases. 

I  agree,  however,  with  Dr.  Maloney,  who  condemns 
Frenkel's  direction  that  the  patient  must  follow  each 
movement  visually.  Reasons  against  this  are  elaborated 
in  Dr.  Maloney's  paper  (The  Cure  of  Ataxia)  but  it 
may  be  briefly  stated  that  the  fixation  of  attention  on 
what  should  be  an  automatic  movement  controlled  by 
kinaesthesia  is  both  theoretically  and  practically  wrong. 

Interest  in  all  physical  exercises  has  been  stimulated  by 
the  better  physical  health  enjoyed  by  our  younger  men 
as  a  result  of  the  exercises  which  have  been  forced  upon 
them  as  a  part  of  their  military  training,  and  Dr.  Wilfred 
Grenfell  has  recorded  how  the  "wasters"  of  the  London 
clubs  have  gained  physically,  mentally  and  morally.1 
The  probability  of  a  large  number  of  wounded  and  crippled 
being  returned  to  this  country  has  also  caused  a  number 
of  individuals  to  consider  how  such  may  be  helped. 
Physical  well  being  is  essential  to  the  crippled  who  are 
usually  disinclined  to  take  any  exercise  for  a  varying 
time  after  they  have  become  convalescent. 

Regarding  the  physical  measures  used  in  caring  for  the 
wounded,  probably  Major  R.  Tait  McKenzie,  Professor 
of  Physical  Education  at  the  University  of  Pennsylvania, 
deserves  more  credit  for  the  excellent  measures  adopted 

1  Red  Cross  and  R.  A.  M.  C.  Atlantic  Monthly,  Vol.  cxviii,  p. 
106,  July,  1916. 


PHYSICAL   EDUCATION  175 

by  the  British  than  any  other  one  man.  He  modestly 
disclaims  this  and  insists  that  the  credit  is  undeserved. 
He  is  the  author  of  several  books1  and  articles.  Among 
the  latter  is  one  entitled  "The  Treatment  of  Nerve, 
Muscle,  and  Joint  Injuries  in  Soldiers  by  Physical 
Means,2  from  which  the  following  is  copied: 

"GYMNASTICS" 

"  Gymnastics  should  be  considered  as  part  of  the  treat- 
ment in  most  cases  whether  the  recovery  is  complete 
or  not,  a  contracted  finger  or  a  stiff  knee  should  not  pre- 
vent the  patient  from  doing  most  of  the  movements  in 
a  gymnastic  table  and  the  general  exercise  and  disci- 
pline contributes  to  his  cure.  The  two  tables  of  Swedish 
remedial  exercises,  designed  and  already  in  use  for  con- 
valescents, are  arranged  with  no  jerky  or  violent  move- 
ments at  first  so  as  to  avoid  the  possibility  of  injury 
from  overstrain.  As  the  patient  improves,  he  may  be 
given  simple  dancing  steps  to  music  and  so  progress  to 
tag  and  other  gymnastic  games.  The  formal  gymnastic 
tables  are  largely  for  discipline,  accuracy,  and  control 
and  should  occupy  but  a  small  part  of  the  hour,  the  rest 
being  given  over  to  games  with  medicine  ball  and 
basket  ball,  or  such  sports  as  handball,  bowling  or  quoits. 
In  this  way  discipline  is  combined  with  treatment  and 
recreation  and  the  man  is  prevented  from  forming  those 
habits  of  idleness  that  unfit  so  many  hospital  patients 
for  civil  life  after  their  discharge. 

OCCUPATIONAL  THERAPY 

"As  soon  as  possible,  men  should  be  set  at  some  occu- 
pation in  which  they  will  use  the  affected  arm  or  leg, 
not  consciously,  but  to  accomplish  some  definite  task. 

1  Exercise  in  Education  and  Medicine.     Philadelphia,  W.   B. 
Saunders  Company.    Reclaiming  the  Maimed.     N.  Y.,  Macmillan 
Co. 

2  Canadian  Medical  Association  Journal,  December,  1917. 


176  RECONSTRUCTION    THERAPY 

Driving  a  nail,  pushing  a  saw,  or  handling  a  spade  will 
supplement  and  soon  replace  the  more  accurate  but 
less  interesting  work  of  the  treatment  room.  The  clumsy 
fingers  become  nimble,  in  typewriting,  weaving,  splicing 
or  modeling  and  the  practice  of  these  trades  must  be  re- 
garded as  important  parts  of  one  general  and  progressive 
system  of  treatment. 

"The  success  of  physical  means  in  the  treatment  in 
these  conditions  depends  on  well-trained  operators. 

"In  Canada  there  are  now  two  schools  turning  out 
graduates  trained  in  the  use  of  electricity,  hydro-therapy, 
radiant  heat,  massage  and  corrective  exercises,  muscular 
and  educational,  and  I  trust  this  will  be  followed  speedily 
by  a  course  for  the  medical  officers  who  will  be  put  in 
charge  of  this  important  department  of  treatment. 
Such  a  course  should  consist  of: 

"1.  Orthopaedics,  to  include  the  use  of  splints  for  all 
orthopaedic  conditions,  the  construction  of  shoes  to 
correct  foot  deformities,  the  demonstration  of  nerve 
suture  and  tendon  transplantation,  the  after  treatment 
of  stumps  and  the  fitting  of  artificial  limbs. 

"2.  Electricity,  to  include  lectures  and  demonstra- 
tions in  the  use  of  galvanism,  faradism,  diathermy,  and 
ionization;  instruction  in  muscle  testing. 

"3.  Hydro-therapy,  to  include  demonstrations  and 
practice  in  the  giving  of  the  douche  and  whirlpool  bath, 
and  the  sedative  bath. 

"4.  Thermo-therapy,  to  include  demonstrations  and 
practice  in  the  use  of  the  lamp  and  cabinet  bath. 

"5.  Massage,  to  consist  of  demonstrations  and  per- 
sonal practice  in  each  form  of  manipulation  including 
passive  movement. 

"6.  Re-education,  to  consist  of  demonstrations  and 
practice  in  the  use  of  each  of  the  appliances  for  re-educa- 
tion provided  by  the  Military  Hospitals  Commission. 

"7.  Gymnastics,  to  include  practice  in  going  through 
two  tables  of  Swedish  remedial  exercises  for  convalescent 
soldiers,  dancing  steps  and  gymnastic  games. 


PHYSICAL   EDU  CATION  177 

"8.  Observation  and  lectures  on  occupational  therapy. 

"Such  a  course  would  prevent  medical  officers  from 
being  put  in  the  false  position  in  which  they  so  often  find 
themselves,  of  having  to  direct  treatment  with  which 
they  are  not  familiar." 

Dr.  McKenzie  states  that  physical  therapy  applies  to 
the  following  conditions: 

"1.  Injury  to  peripheral  nerves,  all  the  way  from  the 
bruising  of  a  nerve  trunk  to  its  destruction,  and  restora- 
tion by  surgical  means. 

"2.  Scar  tissue,  either  in  preparation  for,  or  after 
operation. 

"3.  Old  septic  wounds,  long  since  healed,  are  fre- 
quently painful,  and  a  focus  of  infection  may  be  discov- 
ered by  massage. 

"4.  In  all  post-operative  conditions  the  cure  must  be 
completed  by  physical  means.  It  is  not  enough  to  break 
down  an  adhesion  or  restore  a  joint  to  potential  useful- 
ness. Its  nutrition  must  be  improved,  and  the  patient 
must  be  taught  to  use  it. 

"  5.  Functional  neuroses,  which  take  the  form  of  palsies, 
loss  of  sight,  speech  or  hearing,  areas  of  ansesthesis,  or 
hypersesthesis,  show  many  marvelous  cures  by  physical 
means. 

"6.  The  conditions  variously  grouped  under  the  name 
"shell  shock"  which  vary  all  the  way  from  minute  haem- 
orrhages into  the  brain  substances,  caused  by  concussion, 
to  fear  and  intolerable  weariness  must  be  treated  by 
this  means.  When  the  soldier  in  the  trenches  begins 
to  move  his  head  rhythmically,  to  twitch  his  arm,  or 
clutch  at  the  sound  of  a  shell,  the  regimental  surgeon, 
if  he  is  wise,  sends  him  back  to  the  rest  camp  for  a  week 
or  two.  If  he  is  kept  until  the  inevitable  smash  comes, 
his  recovery  will  be  a  matter  of  months,  at  best,  and  he 
is  usually  put  out  of  commission  permanently.  Tremors 
coarse  and  fine,  up  to  the  point  of  a  general  convulsive 
seizure,  rhythmic  movements,  increasing  when  the 
man  is  spoken  to,  and  calming  down  when  he  is  left 
12 


178  RECONSTRUCTION    THERAPY 

alone  are  characteristic.  Many  of  these  men  are  martial 
misfits,  never  built  for  the  enormous  stress  of  modern 
warfare,  and  rapidly  go  to  pieces  under  it.  They  usually 
present  a  history  of  nervousness,  frequently  with  en- 
larged thyroid,  rapid  pulse  and  prominent  eyes,  and  all 
such  cases  call  for  rest  and  sedative  treatment,  by  the 
continuous  bath  at  skin  temperature  (94  degrees), 
hours  of  rest  in  bed  daily,  and  the  substitution  of  gentle 
massage  and  electricity  for  active  movement  at  first, 
with  a  gradual  increase  of  exercise,  beginning  with  a 
slow  walk  and  ending  with  gymnastic  games  and  voca- 
tional training. 

"7.  The  "soldier's  heart"  is  but  a  symptom  of  over- 
strain. The  rapid  pulse  and  breathlessness,  the  en- 
larged thyroid,  all  show  the  nervous  origin  of  the  condi- 
tions now  known  familiarly  to  medical  officers  as  D.A.H. 
(i.e.,  Disordered  action  of  the  heart).  The  faradic  or 
high-frequency  current,  the  sedative  bath,  gentle  massage 
and  rest  quickly  reduce  a  rapid  pulse  rate  and  allow 
him  to  bear  without  danger,  an  increasing  load  in  the 
form  of  gymnastic  exercise,  walking,  and  manual  labor. 

"8.  Debilities,  whether  due  to  typhoid,  dysentery, 
or  exhaustion  are  built  up  again  and  made  ready  for  serv- 
ice by  graded  exercises  of  effort,  like  light  gymnastics, 
and  of  endurance,  like  walking,  until  they  can  stand 
the  amount  of  work  to  which  they  were  formerly 
accustomed." 

In  this  paper,  Dr.  Mackenzie  does  not  discuss  the  place 
of  physical  exercises  in  the  "treatment  of  sprains  and 
after  fractures,  in  rheumatism  and  gout,  in  flat-foot 
and  other  postural  defects." 

Dr.  McKenzie  has  also  contributed  a  chapter  on  Mas- 
sage, Passive  Movement,  Mechanical  Treatment  and 
Exercise,  to  Dr.  R.  Fortescue  Fox's  excellent  little  book 
entitled  Physical  Remedies  for  Disabled  Soldiers  (New 
York,  1917,  William  Wood  and  Company).  This  book 
is  divided  into  three  parts.  Part  I  on  Hydrological 
Remedies  and  the  Indications  for  their  Use,  describes 


PHYSICAL    EDUCATION  179 

remedial  baths  and  the  indications  for  their  use  in  surgical 
fever,  nervous,  cardiavascular,  rheumatic,  digestive  and 
tubercular  cases.  Part  II  on  Mechanical  and  Electrical 
Remedies  treats  of  forms  of  mechanical  treatment,  the 
chapter  by  Major  McKenzie,  and  chapters  on  the  Admin- 
istration of  Massage  by  Dr.  James  B.  Mennell,  and  Elec- 
tricity and  Radiation,  by  Dr.  Francis  Hernaman-John- 
son.  Part  III  on  the  Provision  for  Physical  Remedies 
treats  of  Physical  Remedies  in  the  Hospital,  the  Physical 
Clinic,  Physical  Remedies,  Re-education  and  Work, 
Physical  Remedies  at  the  British  Spas,  and  British 
Marine  Resorts  and  Climates.  The  book  is  most  valu- 
able for  anyone  taking  up  physical  education. 

While  it  is  impossible  to  more  than  "point  the  way" 
in  a  brief  chapter,  the  reader  should  bear  in  mind  that 
there  are  many  works  of  value  both  in  the  form  of  books 
and  articles.  One  of  the  latter  seems  especially  note- 
worthy. There  are  many  people  whose  feet  are  deformed 
due  to  ill-fitting  shoes.  Personally,  I  hold  the  shoemaker 
responsible  for  this  as  we  buy  what  he  sells  us  or  makes 
for  us.  The  shoemaker  blames  Dame  Fashion  for  his 
nefarious  conduct  forgetting  that  he  sits  up  nights  to 
devise  new  styles.  At  present,  however,  we  are  more 
concerned  with  the  consequences  than  with  placing  any 
blame.  Our  deformed  feet  frequently  cause  a  weakening 
and  bring  about  the  condition  know  as  flat-foot,  as  well 
as  other  changes.  Once  acquired  it  is  difficult  to  get 
rid  of,  but  is  best  helped  by  exercises  which  have  been 
formulated  by  Major  William  W.  Reno,  U.  S.  A.1 

Briefly  stated  the  exercises  are  as  follows.  It  naturally 
adds  interest  as  well  as  endorsement  when  we  know 
that  these  are  used  in  United  States  Training  Camps: 

FEET   EXERCISES 

EXERCISE  I.  Stand  erect,  with  only  toes  projecting 
beyond  edge  of  chair,  board  or  some  Convenient  ledge  or 

iJohn  S.  Gregory.  The  Feet  of  the  Fighting  Men.  The 
World's  Work,  Vol.  xxxiii,  p.  303,  January,  1917. 


180  RECONSTRUCTION    THERAPY 

depression.     Bend  toes  downward  in  gripping  movement. 
Ten  to  thirty  times. 

EXERCISE  II.  Move  forward  a  little  until  half  the  foot 
projects  over  edge  of  board,  or  depression — go  through 
the  same  movement. 

EXERCISE  III.  Entire  foot  rests  on  a  flat  surface — 
without  raising  body  of  foot,  curl  the  toes  back  ten  to 
thirty  times. 

EXERCISE  IV.  This  same  position,  separate  all  the  toes 
ten  to  twenty  times. 

EXERCISE  V.  Turn  toes  slightly  in,  and  heels  out, 
weight  of  body  thrown  on  outer  edge  of  foot,  while  the 
toes  are  bent  downward  and  curled  under  the  foot — 
or  with  weight  of  body  on  the  heels  the  anterior  part 
of  the  entire  foot  is  lifted  as  high  as  possible  from  the 
ground. 

Additional  exercises. 

Bend  foot  downward  from  ankle — ten  times. 
Upward  from  ankle,  ten  times. 
Rotary  movement  of  foot  on  ankle. 

It  must  be  remembered,  also,  that  it  will  frequently 
be  necessary  to  give  special  instruction,  for  example, 
to  teach  a  right-handed  man  to  become  left-handed 
because  he  has  lost  his  right  hand  or  arm.  At  special 
training  centers  it  has  been  found  well  to  have  persons 
similarly  crippled  who  have  become  proficient  in  using 
the  remaining  limb  to  give  instruction  to  those  who  have 
not  yet  learned  this  adaptation.  At  the  Ecole  Profession- 
elle  de  Blesses  at  Montpelier,  M.  Tamenne,  a  Belgian 
refugee  who  lost  his  right  forearm  when  he  was  sixteen 
and  who  has  so  re-educated  his  left  hand  that  he  is  almost 
unconscious  of  the  loss,  has  been  teaching  disabled  man 
how  to  use  their  left  hands.  He  has  formulated  some 
specific  directions  for  writing  which  should  undoubtedly 
be  found  useful.1 

1  The  Lancet,  April  7,  1917,  p.  553.  Abstract  in  Journal  of  the 
American  Medical  Association,  Vol.  Ixviii,  p.  1562,  May  26,  1917, 
also  in  Modern  Hospital,  Vol.  viii,  p.  438,  June,  1917. 


PHYSICAL   EDUCATION  181 

Another  writer  has  suggested  a  method  by  means  of 
which  armless  men  may  be  taught  to  write  with  the  knee.1 
This  impresses  me  as  being  cumbersome  arid  a  rather 
useless  proceeding.  If  the  armless  patient  cannot  be 
fitted  with  one  of  the  excellent  artificial  arms  which  are  on 
the  market,  he  can  be  taught  to  write  with  the  penholder 
held  between  the  teeth,  which  is  a  simpler  and  more  com- 
mon method. 

It  should  be  constantly  kept  in  mind  that  the  benefit 
from  physical  exercises  is  much  greater  if  they  can  be 
carried  out  in  the  open,  where  there  is  an  abundance 
of  fresh  air. 

1  Blachly,  Dr.  Arthur  T.  Apparatus  for  Writing  with  the  Knee. 
Journal  of  the  American  Medical  Association,  Vol.  Ixviii,  p.  1696, 
June  9,  1917. 


CHAPTER  XIII 
OCCUPATIONS  FOR  THE  FEEBLEMINDED 

I  must  confess  to  a  feeling  of  diffidence  in  taking  up 
this  subject  as  my  experience  with  the  feebleminded  is 
rather  limited.  As  I  have  been  particularly  requested 
to  include  such  a  chapter  and  as  there  is  apparently  but 
one  special  work  upon  the  subject,1  I  have  made  a  com- 
pilation from  more  competent  authorities,  in  order  that 
those  needing  it  may  have  references,  at  least,  in  a  con- 
venient form. 

According  to  Dr.  George W.  Jacoby,2  "Edmond  Holmes 
in  his  book,  "What  Is  and  What  Might  Be,"  differentiates 
six  natural  impulses  or  instincts,  as  follows : 

"1.  The  child's  instinctive  desire  to  enter  into  com- 
munion with  the  persons  about  it,  to  talk  to  them,  to 
tell  them  what  it  has  done,  seen,  felt,  thought,  and  to 
hear  what  they  have  to  tell  it.  This  he  calls  the  com- 
municative instinct. 

"2.  The  tendency  of  the  child  to  play  the  role  of  hero, 
fairy,  prince,  adventurer,  giant,  or  dwarf.  This  he  calls 
the  dramatic  instinct. 

"3.  The  desire  of  the  child  to  give  visible  expression, 
through  drawing,  painting  or  plastic  imitation,  to  the 
pictures  which  fill  its  imagination — the  artistic  instinct. 

"4.  The  impulse  of  the  child  to  reproduce  melodies 
by  singing  and  to  execute  their  corresponding  rhythmical 
movements  by  dancing — the  musical  instinct. 

"5.  The  desire  of  the  child  to  know  the  why  and  where- 

1  Bickmore,  A.     Industries  for  the  Feebleminded  and  Imbecile, 
London,  Adlard  &  Son,  1913. 

2  P.  235,  Child  Training  as  an  Exact  Science.     Funk  &  Wagnalls 
Co.,  1914. 

182 


OCCUPATIONS    FOR   THE   FEEBLEMINDED  183 

fore,  the  reason  and  purpose,  of  things — the  inquisitive 
instinct. 

"Q.  The  impulse  of  the  child  to  pull  apart  things  in 
order  to  reconstruct  them — the  constructive  instinct. 

"Of  these,  Holmes  classes  the  first  two  as  sympathetic 
instincts,  the  next  two  as  aesthetic  instincts,  arid  the  last 
two  as  scientific  instincts.  Upon  the  basis  of  these 
natural  impulses  is  built  the  mental  development  of  the 
child." 

Probably  every  one  in  adult  life  knows  of  instances 
where  the  repression  of  such  natural  instincts  has  caused 
a  failure  of  adaptation,  for  example,  a  youth  with  musical 
ability  and  instincts  has  been  forced  into  a  commercial 
career  with  consequent  unhappiness  and  lack  of  success. 
It  is  a  wise  parent  or  teacher  who  can  recognize  the 
child's  capabilities  and  weaknesses  and  so  order  his 
training  that  the  first  is  fostered  and  the  latter  over- 
come, at  least  partially. 

So  also  is  the  occupational  teacher  wise  who  can 
present  to  the  patient  the  occupation  which  will  appeal 
most  strongly  to  his  natural  instincts. 

It  may  be  admitted  without  argument  that  many 
crafts  will  appeal  .to  more  than  one  instinct.  For 
example,  making  a  basket  may  appeal  to  one's  artistic 
as  well  as  constructive  instincts. 

In  regard  to  vocational  training  of  the  feebleminded, 
Dr.  Jacoby  says:  "The  attempt  should  at  least  be  made 
to  teach  them  some  vocation.  Simultaneously  with 
other  instruction  a  certain  training  in  mechanical  dex- 
terity should  be  undertaken.  In  the  beginning  this 
work  may  be  restricted  to  the  performance  of  house- 
hold work.  In  conformity  with  their  greater  bodily 
strength,  the  boys  should  be  urged  to  do  the  heavier 
work,  such  as  carrying  coal,  chopping  wood,  etc.,  while 
the  girls  should  be  induced  to  knit,  sew,  clean  the  house, 
cook,  wash,  etc.  Later  the  children  should,  if  possible, 
be  employed  in  the  field  and  garden,  as  well  as  in  the 
workshop.  The  feebleminded  of  higher  grade  may  be 


184  RECONSTRUCTION    THERAPY 

trained  as  shoemakers,  tailors,  locksmiths,  carpenters,  or 
bookbinders,  those  of  lower  grade  as  basket  or  carpet 
weavers,  rope  and  broom  makers.  For  the  lower  grade 
of  educable  idiots  pursuits  as  simple  and  unvarying  as 
possible  should  be  selected,  such  as  stable  cleaning, 
wood  chopping  and  shoveling  in  the  field  and  garden, 
because  these  occupations,  being  more  easily  remem- 
bered, sooner  become  automatic,  and  because  they  are 
markedly  advantageous  from  the  point  of  view  of  bodily 
hygiene." 

As  in  all  forms  of  occupational  therapy  which  are 
especially  for  mental  training,  the  awakening  of  the 
attention  and  interest  is  one  of  the  most  important  and 
one  of  the  most  difficult  things  about  the  work. 

Shuttleworth  and  Potts'1  4th  edition,  devotes  a  brief 
chapter  to  Industrial  Training  and  Recreation.  They 
recommend  kindergarten  work  as  a  preparation  for 
handicraft,  as  paper  weaving  paves  the  way  for  stocking 
darning.  This  work  also  "trains  the  fingers,  and 
through  them  the  intelligence,"  develops  continuity  of 
attention  and  stimulates  further  effort  by  the  production 
of  a  tangible  result.  It  has  been  frequently  noted  that 
the  feebleminded  learns  more  with  his  hands  than  with 
his  head.  Outdoor  work  is  especially  recommended. 
Among  the  occupations  given  are  nature  study,  the 
making  of  woolen  and  cocoanut  fiber  mats,  cloth  and 
cane  weaving,  simple  brush  and  basket  making,  straw 
plaiting,  macrame,  wood  carving,  knitting,  crocheting, 
printing,  bookbinding,  envelope  and  paper-bag  making, 
cardboard  box  making,  tinware  and  metal  plate  work, 
tailoring,  shoe  making,  wood  carving,  lace  making,  and 
needlework. 

Dr.  Martin  W.  Barr2  gives  interesting  details  of  how 
patients  may  be  given  manual  training  and  occupation. 

1  Mentally  Deficient  Children.     Philadelphia,    1916,    P.    Bla- 
kiston's  Son  &  Co 

2  Mental  Defectives.     Their  History,  Treatment  and  Training. 
Philadelphia,  P.  Blakiston's  Son  &  Co. 


OCCUPATIONS    FOR   THE    FEEBLEMINDED  185 

A  low-grade  imbecile  was  extremely  troublesome  and 
destructive  to  his  clothing.  He  was  first  taught  to  tear 
cloth  into  •  strips  and  arrange  them  in  orderly  piles. 
Then  to  ravel  them  into  threads.  Next  to  knot  these 
threads  together,  a  task  requiring  months  to  learn.  The 
long  string  which  resulted  was  then  wound  into  a  ball, 
which  the  teacher  covered.  The  next  step  was  knitting, 
which  was  finally  learned  after  months  of  effort.  As  a 
result,  an  unruly,  troublesome  boy  had  been  trans- 
formed into  one  who  delighted  in  knitting  caps  for  others. 

It  is  impossible  to  reproduce  here  the  excellent  ideas 
and  descriptions  given  by  Dr.  Barr  without  too  extensive 
quotations  and  a  perusal  of  his  book  is  recommended. 
It  may  be  stated,  however,  that  sloyd  is  recommended 
for  its  progressiveness,  and  the  general  use  of  wood  tools 
for  the  mental  stimulus  they  will  give  the  child.  Paper 
or  cardboard  construction  work  may  be  used  when  more 
convenient  than  wood.  Clay  modeling,  drawing  and 
painting,  are  also  of  value  for  the  mental  development 
of  the  child  and  assist  him  to  do  better  work  later  on 
in  such  trades  as  shoe  making,  tailoring,  carpentry, 
house  painting,  basketry  or  pottery;  or  in  embroidery, 
carving  or  illustrating. 

Dr.  William  W.  Ireland  says1  that  "it  is  of  great  im- 
portance to  teach  imbeciles  to  work.  They  are  naturally 
indolent,  and  work  must  be  made  a  habit  before  it 
becomes  agreeable.  Once  they  have  fairly  learned  it, 
it  may  fill  up  many  dreary  hours  in  their  life,  and  may 
lead  to  their  making  their  bread,  or  being  very  helpful 
to  others.  The  trades  generally  taught  in  training 
schools  are  mat  making,  brush  making,  shoe  making, 
mattress  making,  cane  bottom  and  basket  making,  car- 
pentry, tailoring,  and  the  cultivation  of  the  ground." 
"As  the  pupils  are  of  different  strengths,  capacities,  and 
powers  of  standing  exposure,  a  variety  of  employments 
is  needed." 

1  Mental  Affections  of  Children,  Idiocy,  Imbecility  and  Insanity. 
1898,  Philadelphia,  P.  Blakiston's  Son  &  Co. 


186  RECONSTRUCTION    THERAPY 

Rossy1  gives  the  following  list  of  occupations  for  the 
feebleminded:  farm  work,  carpentry,  basketry,  chair 
caning,  weaving  rugs,  hammocks  and  towels,  making 
rag  carpets,  making  mattresses,  chopping  wood,  making 
wells,  shoe  making,  painting,  plumbing,  printing,  sewing, 
knitting,  embroidering,  tailoring,  laundry,  general  house- 
work and  cooking,  and  possibly  manicuring. 

Always  when  prescribing  occupation,  the  individual's 
needs  and  idiosyncrasies  must  be  kept  in  mind.  This 
holds  true  for  the  feebleminded,  as  well  as  the  neur- 
asthenic, and  may  require  more  patience  to  apply.  As  a 
rule  the  economic  value  of  the. occupation  is  considered 
more  seriously  by  the  former  than  the  latter,  but  thera- 
peutic importance  should  be  paramount.  In  this  way 
the  most  satisfactory  results  will  be  obtained. 

While  all  grades  of  the  feebleminded  undoubtedly  can 
be  better  educated  in  schools  or  institutions  conducted 
for  that  purpose,  there  are  frequently  sufficient  reasons 
why  a  child  should  not  be  sent  to  one.  For  example,  he 
may  be  too  young.  The  mother,  or  governess,  may  be 
able  to  aid  the  mental  development  in  many  ways.  If, 
on  account  of  the  expense,  it  is  not  possible  to  secure  the 
services  of  a  trained  teacher,  there  is  an  excellent  book 
which  may  be  used  as  a  basis  for  this  work.2 

It  is  desirable,  however,  that  all  instruction  and 
exercises  that  are  carried  out  by  the  untrained  should  be 
under  the  direction  of  some  competent  authority. 

As  a  rule,  teaching  form  and  color  is  facilitated  by  the 
use  of"  objects  larger  than  would  be  ordinarily  used  for 
the  same  purpose  with  normal  children. 

1  Occupations     for     Feebleminded.     Modern    Hospital,     Sep- 
tember, 1917. 

2  Wrightson,  Hilda  A.     Games  and  exercise  for  Mental  Defec- 
tives.    Cambridge,  1916,  Caustic-Claflin  Co. 


CHAPTER  XIV 
OCCUPATIONAL  THERAPY  FOR  THE  BLIND 

A  number  of  years  ago  I  had  occasion  to  make  a  study1 
of  the  emotional  reaction  in  persons  who  had  become 
blind  in  adult  life.  I  found  that  there  was  usually 
a  depression  which  began  as  soon  as  the  patient  realized 
that  blindness  was  inevitable.  It  was  at  times  preceded 
by  a  period  of  doubt  during  which  the  patient  could  not 
believe  that  the  specialist's  prognosis  was  correct,  and 
that  blindness  was  really  approaching  During  this 
period  the  patient  would  go  from  physician  to  physician, 
or  would  try  one  quack  remedy  after  another.  This 
phase  was  usually  seen  in  persons  of  the  lower  social  and 
educational  levels.  The  depressed  period  was  of  variable 
duration,  seldom  lasting  over  a  year,  and  disappeared  as 
soon  as  the  patient  realized  that  he  and  those  dependent 
upon  him  would  be  taken  care  of  by  their  own  or  his 
efforts. 

As  a  rule  the  relatives  caring  for  the  patient  were 
responsible  for  the  prolongation  of  the  depression  by 
showing  ill-judged  sympathy  and  coddling,  not  insist- 
ing that  he  learn  to  exercise  personal  care,  and  frequently 
keeping  him  housed  in  close,  ill-ventilated  rooms  with 
little  or  no  physical  exercise.  After  the  patient  had 
been  taught  to  overcome  his  handicap,  and  had  become 
capable  of  earning  at  least  a  part  of  his  living  expenses, 
there  was  an  emotional  change  and  there  followed  a 
condition  of  cheerfulness  which  was  frequently  greater 
than  the  individual's  normal. 

While  I  have  never  had  the  privilege  of  investigating 

1  Mental  State  of  the  Blind.  American  Journal  of  Insanity, 
Vol.  Ixv,  p.  103,  July,  1908. 

187 


188  RECONSTRUCTION    THERAPY 

those  blind  from  birth  I  am  of  the  opinion  that  no  such 
constant  reaction  as  the  above  can  be  observed,  for  those 
born  blind  are  frequently  subnormal,  due  to  the  same 
cause  as  the  blindness. 

The  statement  has  recently  been  made  that  "Their 
(the  blind)  attitude  is  not  an  attitude  of  happiness  but 
rather  an  attitude  of  resignation.  They  are  really  the 
Ishmaelites  of  this  century,  made  so  by  our  economic 
system.  They  are  unable  to  procure  and  maintain 
their  own  homes;  they  have  been  driven  out  of  the  com- 
munity life;  they  are  not  permitted  to  be  a  part  in  any 
industry.  The  blind  have  for  centuries  asked  for  a 
chance,  and  (the  speaker)  is  right  when  he  says  they 
have  been  extended  charity.  This  is  not  due  to  any 
premeditated  purpose  on  the  part  of  society;  it  is  one  of 
the  mistakes  of  our  economic  system."  I  believe  that 
this  opinion  of  the  mental  attitude  of  the  blind  is  a 
mistaken  one  and  that  we  will  find  very  few  persons 
who  are  familiar  with  them  after  they  have  adjusted  them- 
selves to  their  condition  who  will  agree  with  it.  As  I 
have  previously  said,  blindness  is  usually  followed  by  a 
period  of  depression  which  in  time  is  replaced  by  a  con- 
dition of  cheerfulness  above  the  individual's  normal. 
Naturally  in  the  transition  period  we  would  expect  to 
find  an  "attitude  of  resignation."  Possibly  the  patients 
were  not  observed  beyond  this  stage. 

The  evils  of  the  lack  of  occupation  show  more  plainly 
perhaps  in  the  blind  than  in  any  other  group  except  the 
insane.  The  blind  man  who  has  not  been  trained  in 
some  occupation  is  very  apt  to  develop  dissipated  habits 
as  a  relief  from  idleness.  As  a  consequence  he  causes 
trouble  and  becomes  a  nuisance  or  even  menace  to  the 
community. 

Occupational  therapy  for  the  blind  may  be  said  to 
begin  with  the  instruction  given  the  patient  so  that  he 
may  exercise  proper  personal  care.  The  coddling  to 
which  he  has  been  subjected,  and  the  self-pity  which  is 
engendered  whenever  any  one  of  us  suffers  a  physical 


OCCUPATIONAL  THERAPY  FOR  THE  BLIND     189 

or  mental  misfortune,  together  operate  to  diminish  the 
patient's  self-confidence  and  self-reliance. 

It  is  easy  to  understand  that  a  person  who  is  en- 
couraged in  the  belief  that  he  is  helpless  may  soon  have 
this  idea  firmly  fixed  in  his  own  consciousness,  .and 
especially  so  when  he  is  suffering  from  a  physical  infirmity 
which  requires  such  a  radical  re-adjustment  of  his  methods 
of  living  as  blindness  entails.  The  first  step  therefore 
is  to  get  lid  of  this  idea  of  helplessness.  The  statements 
of  the  teacher  that  he  can  do  something  for  himself  will 
probably  be  received  with  incredulity  at  first,  but  its 
repetition  will  in  time  bring  about  a  condition  in  which 
the  patient  is  somewhat  receptive  and  can  be  persuaded 
to  attempt  simple  tasks  of  personal  care  or  to  do  some- 
thing for  his  own  amusement.  He  may  be  taught  to 
comb  and  brush  his  hair  or  to  recognize  the  prickings  on 
a  pack  of  playing  cards  which  have  been  marked  in  order 
that  he  may  play  solitaire  and  so  pass  the  waiting  hours. 
If  a  woman,  a  beginning  may  also  be  made  by  teaching 
her  to  arrange  her  hair. 

Immediately  upon  finding  that  he  can  do  something 
for  himself  the  adult  blind  patient  becomes  more  hope- 
ful and  ambitious  to  learn  other  things  so  that  he  may 
become  still  more  self-reliant.  In  a  short  time  it  may 
be  possible  for  him  to  be  taught  to  take  entire  charge 
of  his  person,  even  to  shaving  himself.  Frequently 
on  his  own  initiative  he  will  do  small  tasks,  thus  further 
increasing  his  self-confidence.  At  this  early  stage  it 
is  extremely  important  to  give  all  the  praise  and  en- 
couragement that  is  possible. 

Early  in  his  training  the  patient  should  be  taught  to 
find  his^way  about  his  dwelling  and  its  immediate  en- 
virons unassisted.  Although  I  have  had  almost  daily  ob- 
servation for  eight  years  of  the  young  blind  woman  who 
operates  our  telephone  switchboard  and  who  does  the 
work  which  is  ordinarily  performed  by  those  at  infor- 
mation desks,  I  have  never  ceased  to  marvel  at  the  way 
she  runs  across  the  hall  and  through  a  doorway  without 


190  RECONSTRUCTION    THERAPY 

mishap.  Many  of  the  adult  blind  have  a  great  deal  of 
feeling  against  the  use  of  a  cane,  or  antenna  as  it  is  fre- 
quently called.  It  is  usually  possible  for  the  blind  to 
entirely  dispense  with  an  antenna  when  in  familiar  sur- 
roundings but  it  is  generally  conceded  that  mishaps 
may  be  avoided  if  one  is  carried  on  the  street,  or  in  fact, 
any  place  other  than  the  dwelling  or  work  place  habitu- 
ally used  by  the  blind  person.  This  view  has  recently 
received  strong  corroboration  from  Philip  E.  Lay  ton.1 
Dr.  Javal  in  his  book  Entre  Aveugles2  also  advocated  the 
use  of  antennae.  This,  by  the  way,  is  an  excellent  work 
to  read  to  the  person  with  failing  eyesight,  or  by  those 
who  care  for  such,  as  it  abounds  with  many  practical 
directions.  Dr.  Emile  Javal  was  a  famous  French  oculist 
who  lost  his  eyesight  suddenly  when  sixty-two  years  old, 
after  which  he  wrote  the  above.  In  the  paper  pre- 
viously mentioned  1  made  a  quotation  from  Dr.  Javal's 
chapter  entitled  "Psychology  of  the  Blind."  While 
throwing  light  upon  the  mental  state  of  those  who  be- 
come blind  in  adult  life  it  also  is  a  strong  endorsement 
of  the  value  of  occupation.  The  quotation  follows: 
"Among  men  who  are  free  from  material  anxieties,  those 
who  have  never  taken  thought  save  of  their  pleasures 
and  of  their  own  affairs  are  the  most  unhappy  when 
they  lose  their  sight.  By  a  sort  of  distributive  justice, 
those,  on  the  contrary,  who  have  set  before  them  as  the 
chief  aim  of  life  to  contribute  to  the  extent  of  their  power 
to  the  general  progress,  find  resources  in  themselves; 
every  one,  whatever  his  social  position  and  his  intel- 
lectual faculties  may  be,  can  always  find  satisfaction  in 
contributing  to  the  happiness  of  another. 

"Men  of  science  occupy  a  privileged  position;  they 

1  The  Inability  to  Travel  Alone  One  of  the  Chief  Causes  of 
Failure  Among  the  Blind.     Outlook  for  the  Blind,  Vol.  xi,  p.  68, 
October,  1917. 

2  On  Becoming  Blind,  Advice  for  the  Use  of  Persons  Losing 
Their   Sight.     Translated   by   C.    E.    Edson,    New  York,  1905, 
Macmillan  and  Co. 


OCCUPATIONAL  THERAPY  FOR  THE  BLIND     191 

have,  in  fact,  a  whole  fund  of  acquired  knowledge  which 
they  can  make  use  of.  So  long  as  they  can  still  bring 
their  stone,  however  small  it  may  be,  to  the  building  of 
civilization  and  progress,  they  feel  that  they  live;  and 
whatever  be  the  wounds  received,  they  are  not  hors  de 
combat — the  inequality  of  arms  only  increases  their  ardor. 
More  happy  still  if,  their  work  having  been  of  use  to 
some  one,  they  can  repeat  with  serenity  the  words  of 
Ecclesiastes,  '  My  heart  rejoiced  in  all  my  labor;  and 
this  was  my  portion  of  all  my  labor.' " 

Having  made  a  start  there  is  usually  little  difficulty 
in  stimulating  the  patient  to  take  up  other  occupations. 
It  is  important  that  he  be  taught  one  of  the  systems  of 
reading  raised  type  by  touch.  There  are  a  number  of 
these,  the  Braille,  Moon,  and  New  York  Point  being 
the  principal  ones.  It  has  been  recently  proved  by  Mr. 
Walter  G.  Holmes  that  the  New  York  Point  is  the  best 
for  several  reasons,  the  most  important  is  that  it  occupies 
less  space  than  the  other  systems,  hence  is  the  most 
economical.  A  movement  has  been  started  to  combine 
the  smaller  characters  of  the  Braille  and  New  York 
Point  to  form  a  Universal  Alphabet. 

The  marked  cards  to  which  reference  has  been  made 
will  often  act  as  a  stimulus  for  the  patient  to  take  up 
the  study  of  reading  by  touch.  This  will  serve  to  pass 
many  hours  which  would  otherwise  be  dull  and  depress- 
ing. The  majority  of  public  libraries  have  books  for 
the  blind  and  the  United  States  Post  Office  Department 
has  made  arrangements  for  the  free  transmission  of  such 
reading  matter  through  the  mails.  A  special  magazine 
called  The  Matilda  Ziegler  Magazine  for  the  Blind  is  pub- 
lished monthly  in  New  York  and  is  distributed  freely.1 
It  deals  with  current  events  and  with  this  magazine  the 
blind  who  cannot  have  a  reader  to  read  them  the  daily 
paper  can  keep  up  with  what  is  going  on  in  the  world. 

At  the  same  time  that  instruction  in  reading  is  being 

1  For  information  address  the  Matilda  Ziegler  Publishing  Com- 
pany for  the  Blind,  250  West  54th  St.,  New  York,  N.  Y. 


192  RECONSTRUCTION   THERAPY 

given  the  patient  should  be  taught  some  forms  of  manual 
work.  It  may  be  possible  for  him  to  adapt  himself  to 
his  former  trade,  such  as  shoe  making,  in  which  case  the 
problem  of  keeping  the  patient  occupied  and  contented, 
and  also  earning  a  part  of  his  upkeep,  is  soon  solved. 
It  is  more  difficult  when  the  patient  is  only  capable  of 
doing  manual  work,  yet  is  unable  to  follow  the  form  he 
pursued  before  he  became  blind  by  reason  of  danger 
or  some  other  cause. 

Some  months  ago  I  was  told  by  an  ophthalmologist 
that  it  was  folly  to  teach  the  blind  manual  trades  as 
they  should  be  taught  to  work  with  their  brains,  and  he 
gave  instances  of  blind  men  whom  he  knew  had  amassed 
large  fortunes.  This  was  evidently  a  statement  made 
without  much  thought,  for  every  one  knows  that  many 
of  the  blind  lack  sufficient  intelligence  to  support  them- 
selves by  mental  work  as  do  many  who  are  physically 
perfect. 

He  also  condemned  broom  making  as  an  occupation  for 
the  blind  although  it  has  for  a  number  of  years  been  re- 
garded as  especially  fitted  for  blind  men.  In  fact,  there 
is  a  strong  sentiment  that  it  be  reserved  for  them.  Many 
persons  will  not  purchase  a  broom  unless  it  has  been  made 
by  a  blind  worker.  As  equipment  and  apparatus  is 
necessary  their  manufacture  is  usually  carried  on  in 
workshops  for  the  blind.  It  is  doubtful,  however,  if 
there  are  a  sufficient  number  of  blind  broom  makers  to 
adequately  supply  our  needs  so  that  the  probability  of 
this  becoming  a  restricted  occupation  is  quite  remote. 

It  is  also  doubtful  if  it  is  possible  to  restrict  the  blind 
to  certain  occupations,  for  while  a,  number  are  obviously 
unsuitable,  such  as  painting,  we  every  now  and  then 
hear  of  a  blind  man  or  woman  doing  something  which 
we  had  heretofore  thought  impossible  for  one  so  handi- 
capped to  accomplish.  Gardening  and  poultry  raising 
are  being  taught  the  blind  English  soldiers.  It  should 
be  stated  that  in  the  last  the  man's  wife  is  also  given  a 
course  of  instruction  so  that  she  may  assist  him.  Blind 


OCCUPATIONAL  THERAPY  FOR  THE  BLIND     193 

men  are  also  being  taught  to  become  stenographers, 
taking  their  notes  by  means  of  a  typewriter  especially 
devised  for  their  use,  the  Braille  typewriter.  The  touch 
system  is  used  on  the  ordinary  typewriter  by  all  first-class 
operators  to  eliminate  fatigue  and  increase  efficiency,  so 
that  we  are  accustomed  to  this  method  and  consequently 
its  use  by  the  blind  causes  slight  wonder.  The  handwrit- 
ing of  the  blind  deteriorates  quite  rapidly  so  that  all  are 
taught  the  use  of  the  machine  and  in  many  schools  the 
pupils  are  provided  with  one  on  their  graduation.  It  is 
very  easy  for  the  blind  man  or  woman  to  become  an 
expert  telephone  operator  where  a  "drop"  switchboard  is 
used.  That  is,  where  a  metal  shutter  drops  down  when 
a  call  is  made  instead  of  a  light  showing.  Weaving 
on  Swedish  looms,  needlework,  basketry  and  many 
other  crafts  are  successfully  carried  on  by  blind  women. 

Netting  is  frequently  taught  to  blind  men  and  is 
excellent  as  an  avocation.  For  one  to  whom  reading  is 
difficult  or  distasteful  it  gives  opportunity  for  a  mild 
stereotyped  physical  exercise  and  employment  of  the 
mind.  By  making  fishing  nets,  tennis  nets,  laundry 
washer  and  other  bags  it  may  be  made  a  vocation. 
The  hammocks  which  are  netted  are  more  expensive  and 
less  comfortable  than  those  woven  by  machinery  and  I 
believe  that  their  manufacture  should  not  be  encouraged. 
An  accomplished  netter  should  know  how  to  make  one 
should  he  receive  an  order,  but  he  should  not  be  en- 
couraged to  believe  that  there  is  a  demand  for  them. 

Basketry  is  one  of  the  best  manual  occupations  for  the 
blind.  Either  as  a  vocation  or  avocation  it  has  great 
value.  A  beginning  should  be  made  with  reed  if  possible, 
although  trade  restrictions  due  to  war  are  apparently 
making  this  a  rare  material.  The  paper  substitutes 
for  it  are  quite  unsatisfactory.  When  sufficient  manual 
dexterity  has  been  acquired  and  the  patient  can  weave 
bases,  sides,  borders,  and  put  on  handles  he  should  be 
taught  the  preparation  and  use  of  willow.  There  is 
always  a  demand  for  baskets  and  a  blind  basket  maker 

13 


194  RECONSTRUCTION    THERAPY 

will  have  no  difficulty  in  securing  employment  if  there 
is  a  factory  in  his  town.  If  there  is  not  and  he  must  carry 
on  his  trade  at  home,  some  arrangement  should  be  made 
so  that  he  can  market  his  products.  From  making 
baskets  to  making  willow  furniture  is  a  short  step,  and 
while  fashions  change,  it  seems  improbable  that  we  will 
give  up  this  beautiful  and  convenient  form  for  many 
years.  On  account  of  changing  fashions  and  demands  it 
is  necessary  that  the  individual  worker  be  kept  informed 
of  new  designs  and  forms  so  that  his  products  may  be 
marketable. 

In  every  phase  of  life,  the  will  to  do  brings  about  the 
accomplishment  of  anything.  The  problem,  therefore, 
is  to  stimulate  the  will  of  the  patient  so  that  he  makes 
the  effort  to  accomplish  the  work  he  has  chosen.  It  is 
difficult  to  be  sure  that  we  always  guide  him  aright 
and  suggest  an  occupation  for  which  he  is  best  fitted, 
therefore,  the  selection  of  an  occupation  should  be  left 
largely  to  his  own  initiative.  As  yet  the  whole  question 
of  suitable  occupations  has  not  been  solved.  Recently 
a  large  electrical  manufacturing  company  has  had  a 
number  of  blind  men  and  women  taught  to  wind  arma- 
tures, thus  opening  a  new  vocation  to  them.  Whether 
it  is  one  for  which  they  are  especially  fitted  it  is  impossible 
to  say.  It  will  be  found  that  the  blind  who  attain  emi- 
nence usually  do  so  in  some  sphere  which  they  have 
chosen  for  themselves.  They  have  had  the  will  to  suc- 
ceed, frequently  in  some  way  which  impresses  us  as  being 
unique  for  one  so  handicapped.  Notable  instances  are 
Henry  Fawcett  (1833-1884)  who  for  many  years  was 
Postmaster-General  of  Great  Britain  and  Professor 
of  Political  Economy  at  Cambridge;  William  H.  Prescott 
(1796-1859),  the  American  historian;  John  Milton 
(1608-1674),  the  poet;  Francois  Huber  (1750-1831), 
a  Swiss  naturalist  who  was  noted  for  his  study  of  bees; 
Senator  Gore  of  recent  memory;  and  many  others.  A 
number  have  done  much  to  improve  the  condition  of  the 
blind,  such  as  Louis  Braille  and  Dr.  William  Moon, 


OCCUPATIONAL  THERAPY  FOR  THE  BLIND     195 

the  inventors  of  the  types  which  bear  their  names; 
Dr.  T.  R.  Armitage  and  Elizabeth  Gilbert,  who  founded 
associations  for  aiding  the  English  blind;  and  W.  H. 
Churchman  and  H.  L.  Hall,  who  did  much  in  this  country. 
Many  have  been  musicians,  theologians,  writers,  lawyers, 
mathematicians,  or  prominent  in  business.  In  every 
instance  it  was  the  will  to  succeed  and  the  determination 
to  overcome  difficulties  which  brought  success.  Prob- 
ably each  one  of  us  knows  of  individuals,  who,  though 
handicapped  in  some  way,  have  made  a  success  in  some 
chosen  vocation  because  they  have  had  the  will  and  the 
determination  to  succeed  in  it. 

It  is  extremely  important  with  the  blind,  as  well  as 
with  the  crippled,  that  they  be  taught  how  to  amuse 
themselves  and  satisfy  the  play  impulse,  in  part  at  least. 
Card  games,  checkers,  chess  and  a  number  of  others  are 
easily  available.  Music  is  often  enjoyed  and  many 
of  the  blind  become  experts  with  the  aid  of  a  reader  or 
secretary.  But  none  of  these  entirely  fill  the  need  for 
recreation  because  there  is  little  physical  exercise  or 
movement  connected  with  them.  The  blind  are  espe- 
cially prone  to  avoid  physical  exercises,  although  I  believe 
that  the  majority  of  us  have  the  same  fault.  They 
should  be  taught  simple  calisthenics  which  can  be  car- 
ried on  alone  after  rising  or  before  retiring  Regular 
outdoor  exercise  should  also  be  taken  each  day  even 
though  this  be  limited  to  walking.  If  it  is  impossible 
for  the  blind  man  or  woman  to  have  a  companion  to 
guide  them  in  their  daily  walk  it  is  usually  possible  to 
find  some  familiar,  even  though  restricted,  area  where 
they  can  walk  to  and  fro  for  a  certain  period  of  time. 
The  blind  man  or  woman  living  in  the  country  usually 
has  better  opportunity  for  outdoor  exercise  than  the 
city  dweller.  Chopping  or  sawing  wood,  husking  corn, 
and  similar  tasks  have  a  greater  value  as  light  physical 
exercises  because  they  are  usually  carried  on  out  of  doors 
or  in  an  airy  place. 

Dancing  is  an  excellent  exercise  and  round  dances 


196  RECONSTRUCTION   THERAPY 

with  a  guiding  partner  may  be  a  great  pleasure  to  the 
blind.  Dr.  Javal  found  benefit  and  enjoyment  in  pro- 
pelling a  tandem  tricycle  with  an  attendant.  Other 
forms  of  exercise  will  be  suggested  by  the  tastes  and 
inclinations  of  individual  patients.  We  are  usually 
surprised  when  we  first  learn  that  blind  boys  and  girls 
take  part  in  athletic  contests  and  games.  While  older 
patients  may  not  care  for  such  strenuous  forms,  at  least 
a  small  part  of  the  day  should  be  given  up  to  some  active 
outdoor  exercise. 

It  is  important  that  instruction  of  the  blind  should  only 
be  undertaken  by  those  who  have  been  properly  trained. 
Unless  this  is  done  mistakes  may  be  made  which  will 
prove  discouraging  to  the  pupil.  It  is  possible,  however, 
for  any  one  with  intelligence  and  an  active  interest  to 
co-operate  in  such  instructions  and  materially  assist  the 
patient. 


CHAPTER  XV 
OCCUPATIONAL  THERAPY  AND  SOCIAL  SERVICE 

Elsewhere1  I  have  detailed  a  plan  for  the  Organization 
of  the  Re-educational  Facilities  of  a  Community  which 
is  here  reproduced: 

A  Plan  for  the  Organization  of  the  Re-educational  Facili- 
ties of  a  Community. — By  William  Rush  Dunton,  Jr., 
M.D. 

The  plan  which  is  outlined  in  this  paper  is  at  present 
being  worked  out  in  Baltimore  and  vicinity.  It  is  be- 
lieved that  it  gives  a  splendid  opportunity  for  the  eco- 
nomic improvement  of  a  community  at  the  present  time 
and  will  also  provide  an  organization  which  can  ade- 
quately handle  the  problem  of  the  returned  crippled 
soldier. 

The  experience  of  Canada  affords  many  lessons  of 
which  our  governmental  departments  apparently  have 
been  slow  to  take  advantage.  It  must,  however,  be 
remembered  that  there  is  a  great  deal  to  be  done  in 
getting  our  soldiers  into  active  service,  and  it  is  but 
natural  to  permit  such  problems  as  the  returned  soldier 
to  wait  until  the  more  pressing  ones  are  solved.  It  is 
indeed  a  question  whether  the  brunt  of  caring  for  the 
returned  soldier  is  not  more  of  a  community  problem 
than  a  governmental  one,  but  even  so,  until  the  soldier 
is  discharged  from  service  he  is  in  charge  of  the  War 
Department  and  the  community  can  do  nothing  without 
its  sanction.  It  is  believed,  however,  that  some  arrange- 
ment can  be  made  by  which  the  government  and  the 
community  can  work  together. 

While  the  Canadian  Military  Hospitals  Commission 

1  Proceedings  of  First  Annual  Meeting  of  the  National  Society 
for  the  Promotion  of  Occupational  Therapy. 

197 


198  RECONSTRUCTION    THERAPY 

has  done  much  they  have  been  unable  alone  to  solve 
the  problem  of  placing  the  cripple  who  has  been  trained. 
It  has  been  necessary  to  enlist  the  aid  and  sympathy  of 
the  general  public.  The  French  have  met  the  same 
difficulties  and  I  feel  that  our  society  can  do  its  bit  by 
aiding  the  various  social  agencies  to  re-educate  and  re- 
habilitate some  of  their  cripples  and  pensioners  and  re- 
store them  to  a  place  in  the  community.  As  an  example 
I  might  instance  the  splendid  work  which  has  been  done 
at  the  Chicago  Experiment  Station  by  Mrs.  Slagle  and  her 
assistants.  Here  already  is  the  nucleus  for  such  work, 
although  the  re-educational  measures  have  been  limited 
to  mental  invalids.  With  the  practice  gained  in  such 
work  the  social  agencies  will  be  prepared  to  handle  the 
larger  numbers  who  will  inevitably  be  brought  home, 
and  we  have  already  heard  of  the  possibility  of  the  in- 
valids of  other  nations  being  brought  to  this  country. 
It  is  a  comparatively  simple  matter  to  train  individuals 
in  a  craft  or  occupation.  Suppose  a  carpenter  has  had 
both  legs  crushed  necessitating  amputation.  With  his 
knowledge  of  wood  working  tools  about  all  we  have  to  do 
is  to  furnish  him  with  designs  and  materials  and  he  is 
able  to  make  attractive  bird  houses.  But  of  what  use 
is  it  unless  he  is  also  provided  with  some  means  of  dis- 
posing of  them.  Then  too,  fashions  in  bird  houses  change 
and  a  small  community  will  soon  be  well  supplied,  so 
that  it  becomes  necessary  to  start  all  over  again  and 
give  him  something  else  to  make.  Possibly  we  can 
suggest  something  for  which  there  is  a  steady  demand, 
or  can  find  him  a  position  in  a  manufactory  where  he 
can  sit  before  a  bench  and  nail  covers  on  small  wooden 
boxes.  To  do  the  latter,  the  employer  must  be  convinced 
that  a  legless  man  can  do  this  sort  of  work  satisfactorily, 
or  if  necessary  to  provide  an  untrained  helper  to  place 
the  boxes  within  reach,  the  employer  and  our  patient 
must  reach  an  amicable  arrangement  to  share  this  extra 
charge.  It  seems  to  me,  therefore,  that  the  first  thing 
to  be  done  is  to : 


OCCUPATIONAL   THERAPY   AND    SOCIAL    SERVICE     199 

1.  Canvass  Employers  to  Ascertain  if  They  Will  Employ 
Cripples  and  Part  Time  Workers. — On  account  of  overhead 
charges  (rent,  heat,  light,  etc.)  it  is  but  natural  for  em- 
ployers to  refuse  to  employ  part  time  workers,  but  it  is 
conceivable  that  they  would  be  willing  to  employ  several 
shifts  of  such  workers  and  so  reduce  the  per  capita  over- 
head charges.     It  is  also  conceivable  that  our  patients 
can  be  induced  to  agree  to  such  an  arrangement. 

The  Canadian  Hospitals  Commission  has  done  excel- 
lent work  in  training  the  crippled  soldiers  in  new  voca- 
tions or  modifications  of  their  old  ones,  so  that  individuals 
have  been  known  to  gain  a  higher  wage  than  when  un- 
handicapped.  For  this  purpose  the  Commission  has  a 
large  staff  of  vocational  teachers  who  are  on  duty  at 
the  various  schools  which  have  been  established  at  the 
convalescent  hospitals.  As  none  of  our  social  agencies 
have  funds  for  this  purpose  it  will  be  necessary  to  secure 
volunteers,  so  that  our  second  step  is  to 

2.  Canvass    Technical   Schools    and    Teachers,    School 
Teachers,  and  Various  Crafts  and  Trades  to  Ascertain  if 
They  Will  Give  Free  Instruction  When  It  is  Desired. — For 
a  number  of  reasons  it  may  be  impossible  for  our  patients 
to  go  to  shops  and  it  will  be  necessary  to  provide  them 
with  some  form  of  work  which  they  can  do  at  home. 
Much  to  my  surprise  I  recently  learned  that  labels  are 
occasionally  pasted  on  match  boxes  by  hand.     I  had 
thought  that  this  was  always  done  by  machinery  and 
that  hand  made  match  boxes  and  labeling  had  "gone 
out"  with  the  time  of  Dickens.     There  may  be  a  num- 
ber of  such  simple  occupations,  so  that  we  must 

3.  Ascertain  the  Forms  of  Work  Which  Can  be  Carried 
on  at  Home  Which  Have  a  Commercial  Value. — Certain 
patients,  probably  the   majority  of   them  women,  are 
able  to  make  articles  which  have  a  commercial  value 
but  for  which  they  have  no  market.     They  may  lack  the 
initiative  necessary  to  create  one.     For  these  we  must 

4.  Ascertain  the  Best  Way  of  Disposing  of  Products. — 
Possibly  Women's  Exchanges  can  be  utilized  for  this. 


200  RECONSTRUCTION    THERAPY 

In  this  connection  it  must  be  remembered  that  the  cost 
of  selling  an  article  is  usually  25  per  cent,  of  its  selling 
price. 

It  is  believed  that  occupational  teachers  are  well 
fitted  by  training  and  practice  to  give  advice  as  to  the 
occupations  which  the  handicapped  may  pursue,  so 
that  a  further  service  to  the  community  may  be  to 

5.  Advise  With  Charity  Workers  and  Others  as  to  the 
Most  Suitable  Occupation  for  Individuals. — But  before  this 
can  be  done  we  must  know  the  capabilities  of  the  patient, 
and  especially  is  this  true  in  the  case  of  the  cripple. 
I  need  only  refer  to  the  work  of  Professor  Amar  in 
France    and    Dr.  Bourillon  in    Belgium  who  carefully 
test  the  patients  to  ascertain  their  physical  capabilities. 
Trained'men  and  rather  expensive  apparatus  is  necessary 
so  that 

6.  A  Consulting  Staff  Should  be  Formed  of  a  Number  of 
Specialists  Consisting  of  at  Least  One  Psychologist,  Ortho- 
pedist, Surgeon,  Aurist,  Ophthalmologist,  Etc.,  to  Test  Our 
Patients. — It  has  been  found  that  some  of  the  handi- 
capped are  able  to  carry  on  certain  trades  especially  well. 
Their  defect  does  not  seriously  interfere  with  the  work. 
1  might  instance  broom  making,  which  is  done  so  well 
by  the  blind.     It  seems  proper,  therefore  to 

7.  Conduct  a  Propaganda  to  Restrict  Certain  Occupations 
to   Certain  Forms   of  the  Handicapped. — Recently   my 
attention  was  called  to  two  advertisements.     One  for 
men  to  shell  cocoanuts — "Work  which  can  be  done  by 
one-legged   men."     The  other  for  workers  in  a  noisy 
factory — "For  which  a  deaf  person  was  well  fitted." 
The  tuberculous  should  not  be  lost  sight  of  in  this 
step. 

Lastly,  the  interest  of  everyone  should  be  enlisted  to 

8.  Gather  References  to  Occupational  Therapy  and  Classify 
Them. — So  much  is  being  published,  and  in  such  un- 
expected places  that  it  is  extremely  difficult  to  keep 
track  of  all  the  articles  that  appear,  the  instances  where 
the    handicapped    have    succeeded,    and     the  unusual 


OCCUPATIONAL    THERAPY   AND    SOCIAL    SERVICE     201 

occupations  which  may  be  undertaken  by  them.  It 
was  recently  suggested  to  me  that  one-armed  and  legless 
men  could  be  utilized  as  traffic  policemen.  Mr.  Gilbreth 
has  proved  that  a  deaf,  one-armed,  one-eyed,"  legless 
man  can  carry  on  the  new  occupation  of  dental  nurse 
which  he  proposes  as  an  economic  asset  to  the  com- 
munity. His  paper  on  the  subject  is  most  interesting 
and  convincing. 

I  believe  that  all  of  the  steps  which  have  been  proposed, 
if  carried  out,  will  tend  to  make  for  personal  and  com- 
munity efficiency.  That  they  will  require  personal 
sacrifice  of  time  and  effort  on  the  part  of  those  behind 
the  movement  is  perhaps  more  obvious,  but  by  active 
co-operation  of  the  social  agencies,  the  consulting  staff, 
ergotherapeutists,  and  various  trade  organizations,  the 
work  will  be  made  easier.  It  should  be  noted  that  the 
active  co-operation  of  each  one  of  these  groups  is  absolutely 
necessary  for  the  success  of  our  movement.  A  house 
may  be  built  with  only  a  roof,  as  the  so-called  dog  tent, 
but  it  is  a  much  better  dwelling  if  it  has  walls,  floor,  etc. 
Just  so  with  pur  plan.  For  completeness  and  effective- 
ness there  is  needed  a  number  of  different  agencies, 
each  one  "doing  his  bit"  to  make  the  whole  practically 
effective.  The  consultant's  opinion  that  John  Jones 
can  use  his  left  arm  stump  to  aid  in  pushing  a  lawn 
mower  has  a  negative  value  unless  he  is  taught  how 
to  do  it  by  the  ergotherapeutist,  and  the  social  agent 
helps  him  to  find  a  lawn  mower  to  push  and  lawns  to 
mow. 

Finally,  the  community  which  carries  out  the  plan  as 
outlined  will  be  prepared  to  care  for  an  influx  of  war 
cripples  and  to  turn  what  would  otherwise  be  an  economic 
loss  into  an  economic  asset. 


It  would  seem  that  some  such  plan  might  be  carried 
out  in  almost  any  community.  It  is  necessary  that  an 
individual,  or  a  group  so  qualify  themselves  that  he  or 


202  RECONSTRUCTION    THERAPY 

they  may  serve  as  experts  and  consultants  in  the  com- 
munity in  which  they  live.  There  are  industrial  cripples 
in  every  locality,  or  those  defective  by  disease.  If  these 
can  be  educated  to  be  only  partially  self-supporting  a 
distinct  economic  service  will  be  conferred  upon  the 
community. 

Further,  while  the  United  States  government  will 
undoubtedly  take  measures  for  the  rehabilitation  of 
war  cripples  and  give  them  vocational  education,  they 
will  eventually  return  to  their  old  homes,  or  go  to  other 
places.  It  will  be  necessary  to  provide  some  oversight 
over  them  that  they  may  be  kept  employed,  that  they 
do  not  lose  courage,  and  perhaps  that  further  instruction 
be  given  them.  The  social  agencies  can  undoubtedly 
do  much  to  aid  but  it  is  readily  conceivable  that  the 
ergotherapeutist  can  also  do  much  by  giving  expert 
advice  and  thereby  save  useless  or  wasteful  efforts  of 
those  less  qualified. 

Canada  has  found  that  social  service  or  follow-up 
work  is  necessary  to  prevent  the  discharged  soldiers 
from  becoming  discouraged  and  giving  up  the  positions 
or  work  for  which  they  had  been  trained.  In  our  own 
country  the  Red  Cross,  through  its  Home  Service,  is 
preparing  to  take  up  this  work. 


CHAPTER  XVI 
CONCLUSION 

It  is  hoped  that  the  preceding  chapters  will  be  found 
helpful  to  those  who  may  be  responsible  for  the  direction 
of  occupational  therapy.  Much  more  might  have  been 
said  but  perhaps  sufficient  information  has  been  given. 

It  must  be  understood  that  there  are  many  problems 
yet  to  be  solved,  and  it  is  hoped  that  they  will  attract 
the  attention  of  the  research  worker.  There  are  many 
difficulties  to  be  encountered,  chiefly  centered  about  the 
emotional  reaction  of  the  patient.  Why  does  one  form 
of  work,  say  carpentry,  appeal  to  one  man  and  not  to 
another,  when  they  are  apparently  of  similar  mental 
caliber  and  from  the  same  social  level?  Is  it  due  to 
some  association,  to  a  difference  in  training  (which  may 
be  practically  equivalent  to  the  same  thing)  or  to  some 
other  factor?  Again  if  two  men  like  wood  work,  why 
does  one  prefer  to  make  bird  houses  and  the  other  toys? 
These  are  very  simple  questions,  and  yet  it  can  readily 
be  seen  are  difficult  to  answer.  Why  do  you  prefer 
Camembert  to  Roquefort?  Or  Verdi  to  Wagner? 
In  all  probability  the  answer  lies  somewhere  in  the  as- 
sociative activities,  but  how  can  we  most  quickly  stimu- 
late the  association  which  will  give  us  the  best  co-opera- 
tion of  the  patient?  Or  to  put  it  differently,  arouse  his 
interest.  As  results  of  any  psychological  processes  are 
usually  slow  in  being  reached,  and  as  they  must  be 
corroborated  by  a  number  of  different  observers,  it  is 
incumbent  on  all  of  us  to  record  our  observations  in  order 
that  in  time  accurate  knowledge  may  result. 

Probably  more  difficulties  are  to  be  encountered  among 
the  mentally  sick  than  in  other  groups,  yet  we  know  that 

203 


204  RECONSTRUCTION    THERAPY 

considerable  accurate  information  has  come  to  us  from 
the  psychiatrists  of  bygone  days.  There  are  a  number 
of  questions  regarding  work  in  this  group  which  should 
be  solved.  Perhaps  the  most  important  is — How  long 
shall  the  working  periods  be  in  order  to  avoid  fatigue 
and  keep  up  the  interest  of  the  patient?  This  will 
probably  have  to  be  considered  from  the  standpoint  of 
different  crafts  and  forms  of  work.  I  have  known  hourly 
periods  to  permit  of  but  little  more  than  a  "start"  at 
a  given  task  with  a  consequent  feeling  of  dissatisfaction 
in  the  patient.  Again  an  hour  and  a  half  of  basketry 
has  produced  quite  marked  fatigue  in  the  same  mild 
case  of  neurasthenia. 

What  length  of  time  shall  the  patient  spend  on  a  given 
occupation?  Here  the  kind,  the  intellectual  level  and 
the  mood  must  all  be  considered,  but  especially  the  end 
result  for  which  we  are  striving. 

What  form  of  occupation  shall  be  given  to  the  hypo- 
maniacal  case?  I  believe  that  it  should  be  simple, 
and  of  a  somewhat  stereotyped  character  in  order  that 
there  should  be  little  or  no  stimulus  to  the  patient's 
already  active  associative  functions,  but  wish  this 
opinion  corroborated  by  the  observations  of  others. 

How  much  effort,  how  much  time,  shall  be  expended 
by  the  nurse  or  teacher  in  stimulating  a  patient  to  take 
up  occupation?  Several  writers,  among  them  Dr. 
Herbert  J.  Hall1  and  Mr.  George  Edward  Barton,2 
have  emphasized  the  fact  that  a  large  amount  of  potential 
labor  is  going  to  waste  in  our  hospitals  and  other  elee- 
mosynary institutions.  Granting  that  every  effort 
should  be  made  to  promote  recovery,  that  no  time-sav- 
ing or  expense-saving  consideration  should  deter  us 
from  attempting  to  restore  a  sick  mind  to  mental  health, 
it  seems  to  me  that  there  should  be  a  limit  to  the  time  and 
effort  expended  in  transforming  the  unwilling  worker 
into  a  regular  toiler  in  an  industrial  shop.  I  believe 

1  The  Work  of  Our  Hands.     Moffat,  Yard  &  Co. 

2  Re-education.     Houghton,  Mifflin  &  Co. 


CONCLUSION  205 

that  often  time  and  effort  are  wasted  by  the  teacher 
when  the  same  result  might  be  accomplished  differently. 
For  example,  when  a  patient  refuses  to  go  to  the  indus- 
trial shop  or  handicraft  class,  it  is  useless  to  spend  a 
great  deal  of  time  in  persuasion.  A  better  plan  is  to 
cease  all  attention  to  the  obstinate  one  and  to  expend 
the  efforts  on  his  or  .her  neighbors.  At  the  same  time 
induce  one  of  those  neighbors  to  take  an  interest  in  the 
stubborn  one  and  persuade  him  to  work.  Sometimes 
a  certain  caste  feeling  can  be  created  with  the  aid  of 
patients,  so  that  idleness  is  looked  down  upon  as  some- 
thing of  which  to  be  ashamed,  as  it  is  in  all  normal 
American  communities.  It  frequently  helps  if  some 
special  privilege  is  given  to  those  who  work  in  the  shops, 
which  brings  up  another  question,  that  of  rewards. 

Shall  patients  be  rewarded?  If  so,  how?  It  is 
probably  easier  to  solve  the  question  of  rewards  in  a 
hospital  having  a  large  population  than  in  a  small  one. 
A  comprehensive  answer  which  will  cover  all  kinds  of 
hospitals  has  not  yet  been  formulated.  A  special 
dietary,  special  quarters,  extra  liberties,  have  all  been 
tried  as  well  as  a  system  of  scrip1  by  means  of  which  the 
patients  were  able  to  purchase  luxuries  like  candy  and 
tobacco  at  the  hospital  shop.  Probably,  the  giving 
of  special  diet  and  privileges  is  the  best  method  of  en- 
couraging workers  in  small  hospitals,  but  do  not  forget 
that  judicious  praise,  even  of  small  effort,  has  great 
value.  This  like  many  other  questions,  will  require  a 
further  period  of  investigation  before  decided  answers 
can  be  given. 

In  his  introduction  to  Mr.  Boring's  paper  (see  p.  33) 
Dr.  Franz  also  asks  a  number  of  questions  which  should 
certainly  be  answered  if  we  are  to  place  the  subject  of 

1  One  of  the  most  recent  scrip  experiments  was  at  The  Common- 
wealth of  Sea  View  Farms,  West  New  Brighton,  Staten  Island, 
N.  Y.,  under  the  Department  of  Public  Charities  of  the  City  of 
New  York.  This  experiment  was  abandoned  on  account  of  a 
change  in  administration. 


206  RECONSTRUCTION    THERAPY 

occupation  therapy  upon  a  scientific  basis.  He  states 
that  the  most  important  angles  from  which  the  subject 
may  be  viewed  are  the  therapeutic  or  prescription  angle 
and  the  economic  or  financial  angle.  "If  the  matter 
be  looked  at  from  one  angle  without  considering  others, 
there  must  be  a  loss  to  the  patients  because  of  this  one- 
sided view,  and  it  is  only  by  a  proper  adjustment  of 
observations  from  all  angles  that  a  correct  and  equitable 
solution  of  the  complex  problem  or  problems  will  be 
reached,  and  the  patients  thereby  receive  the  greatest 
benefit. 

"  The  psychiatrist  who  has  charge  of  a  ward  containing 
100  patients,  or  of  a  hospital  containing  several  thousand 
patients,  has  a  number  of  questions  to  ask. 

"  Is  occupation  a  measure  for  the  relief  or  retardation  of  mental 
disease?" 

"  Is  it  beneficial  in  all  mental  diseases?" 

"  If  not,  in  what  diseases  is  it  beneficial?" 

"  To  what  extent  should  this  therapeutic  measure  be  used, 
and  in  what  stages  of  the  disease  is  it  indicated  or  contraindicated?" 

"Is  it  harmful  to  certain  patients,  irrespective  of  the  type  of 
mental  disease?' 

"These  questions,  and  many  others,  cannot  be 
answered  definitely  at  the  present  time.  They  will 
demand  for  solution  the  attention  of  many  workers, 
using  the  best  scientific  methods,  before  definite  answers 
can  be  given  and  before  reasonable  prescriptions  of 
occupation  can  be  formulated. 

"The  local  financial  and  the  broader  economic  aspects 
demand  attention  in  a  thorough  consideration  of  the 
subject  but  the  latter  have  little  bearing  upon  the  wel- 
fare of  the  patient  and  will  not  be  dealt  with  here." 

"Assuming  the  general  therapeutic  value  of  occupation 
to  be  established,  there  are  a  number  of  questions  to 
be  answered: 

"What  kind  of  occupation  is  best  fitted  to  restore  cer- 
tain types  of  patients  to  mental  health?" 


CONCLUSION  207 

"Are  the  common  tasks  of  the  home,  of  the  farm,  or 
of  the  factory  useful  means  of  bringing  about  cures?" 

"Or,  are  those  occupations  of  a  nature  less  familiar 
to  the  patient  the  more  beneficial  to  him?" 

It  must  be  understood  that  I  am  in  complete  sympathy 
with  scientific^methods  and  scientific  research,  but  we 
must  not  despise  empiricism.  Centuries  before  Newton 
discovered  the  law  of  gravitation,  warring  nations  and 
tribes  took  advantage  of  that  force  to  repel  enemies  by 
hurling  stones  down  upon  them.  The  valuable  prop- 
erties of  many  of  our  drugs  were  known  a  long  time  before 
scientific  investigation  disclosed  the  manner  of  then*  ac- 
tion. At  the  present  time,  it  is  doubtful  if  the  majority 
of  physicians,  when  prescribing  certain  drugs,  give  much 
thought  to  the  results  which  have  been  achieved  by 
laboratory  investigation.  It  can  readily  be  conceded, 
however,  that  laboratory  or  scientific  investigation  of 
such  drugs  has  given  an  exactness  of  dosage  which  is 
not  possible  by  empiric  means,  and  has  often  discovered 
other  effects  than  those  noted  by  the  empiricist.  For 
these  reasons,  if  no  other,  the  scientific  investigation  of 
occupation  therapy  will  be  most  heartily  welcomed,  but 
in  the  meantime  let  us  continue  to  welcome  the  "casual 
observations"  of  the  subject,  hoping  that  they  will 
eventually  be  corroborated  by  scientific  observations. 
Dr.  Franz  asks:  "Is  occupation  a  measure  for  the 
relief  or  retardation  of  certain  mental  diseases?"  There 
can  be  no  doubt,  to  the  careful  observer,  that  in  depres- 
sion and  in  dementia  prascox  occupations  which  arouse 
the  interest  of  the  patient  and  focus  his  attention  upon 
them,  relieve  and  retard  the  progress  of  the  malady  by 
replacement  with  a  more  healthy  manner  of  thinking.  It 
is  also  true  that  the  emotions  control  the  bodily  functions 
and  these  in  turn  influence  the  mood  or  thought,  so  that 
we  have  what  may  be  termed  a  vicious  circle.  This  has 
been  very  well  shown  by  Dr.  George  A.  Crile.1  We 
therefore  find  that  our  cases  of  depression  and  of  demen- 
1  Man,  An  Adaptive  Mechanism.  New  York,  Macmillan  Co. 


208  RECONSTRUCTION    THERAPY 

tia  prsecox  show  physical  improvement  coincident 
with  the  mental. 

Dr.  Franz's  other  questions  cannot  be  so  easily  ans- 
wered, but  I  believe  that  occupation  is  good  in  all  forms 
of  mental  disease,  excepting  delirium  and  acute  excite- 
ment, and  even  in  these  I  am  hopeful  that  we  shall 
eventually  find  that  some  forms  of  work  will  produce  a 
soothing  effect. 

As  to  the  extent  to  which  occupation  should  be  used, 
and  in  what  stages  it  is  indicated  or  contraindicated, 
we  must  answer  that  no  work  should  be  given  to  the 
point  of  physical  and  mental  fatigue,  and  that,  as  is 
said  above,  certain  forms  of  work  are  indicated  and 
certain  others  are  contraindicated,  depending  upon 
many  factors.  Some  forms  may  be  harmful  in  certain 
conditions.  In  prescribing  the  form  of  occupation  to 
be  used  we  must  consider  the  individual  rather  than  the 
disease  from  which  he  is  suffering.  The  "common 
tasks"  of  life  are  probably  more  useful  in  restoring  the 
intellectual  worker  to  mental  health  because  they  are 
"less  familiar." 

It  may  be  said  that  practically  all  of  Mr.  Boring's 
conclusions  had  already  been  reached  by  empirical 
observation.  Of  his  seventh  ("There  is  indication 
that  employment  may  be  beneficial  to  some  patients, 
although  this  cannot  be  asserted  positively"),  clinical 
observations  have  for  years  shown  that  many  patients 
are  benefited  by  employment. 

In  fact  many  observers  believe  that  occupation  benefits 
all  individuals.  Sir  John  Collie  has  said:1  "Personally, 
I  have  always  believed  that  hard  and  continuous  work 
is  the  only  way  to  be  really  happy,  and  that  work  in 
one  form  or  another  is  the  only  salvation  for  those  who 
are  suffering  from  functional  nervous  disease.  I  have 
preached  this  in  season  and  out  of  season  for  a  period 
of  ten  to  fifteen  years,  and  it  is  a  great  satisfaction 

1  The  Management  of  War  Neuroses  and  Allied  Disorders  in  the 
Army.  Mental  Hygiene,  Vol.  ii,  p.  1,  January,  1918. 


CONCLUSION  209 

to  know  that  so  high  an  authority  as  Major  Mott  has 
endorsed  this  view  in  his  practice  at  the  Maudsley 
Hospital."  Dr.  F.  H.  Sexton,  of  Halifax,  in  an  address 
delivered  at  Rochester,  N.  Y.,  November  15,  1917,  said: 
"I  do  not  suppose  that  there  is  anybody  that  does  not 
know  that  work  is  the  greatest  curative  in  the  world." 
Other  quotations  might  be  given  but  why  multiply 
them  when  every  clear  thinking  man  if  he  but  analyze 
his  own  experience  knows  that  the  greatest  good  and 
the  greatest  happiness  in  his  life  has  come  from  work 
well  done. 

As  a  final  word  I  want  to  exhort  the  occupational 
director  to  remember  to  enlist  the  co-operation  of  fresh 
air  and  outdoor  work.  For  a  great  part  of  the  year, 
it  is  possible  to  have  considerable  work  going  on  out  of 
doors. 

More  encouragement  should  also  be  given  to  definite 
outdoor  occupations  like  gardening,  poultry  raising, 
bee  keeping,  as  well  as  the  outdoor  games.  A  pleasant 
change  is  often  appreciated  when  a  basketry  or  sewing 
class  is  held  on  the  lawn.  Where  equipment  cannot  be 
moved,  as  in  printing,  the  room  should  be  light  and  airy. 

In  the  foregoing  pages  an  effort  has  been  made  to  very 
briefly  indicate  the  duties  of  the  occupation  director. 
While  much  more  detail  might  have  been  given  it  was  felt 
that  it  would  have  clouded  the  main  questions,  and  that 
such  detail  would  best  be  worked  out  by  the  director 
who  is  familiar  with  his  own  local  conditions.  It  is 
hoped  that  what  has  been  written  will  be  found  help- 
ful to  those  concerned  with  occupational  therapy  and 
especially  to  those  who  have  charge  of  such  work  in 
institutions. 

Recent  events  in  this  and  other  countries  have  brought 
about  an  increasing  knowledge  by  the  general  public  of 
the  value  of  work  as  a  remedy.  With  this  we  may  hope 
that  our  occupational  therapy  may  become  reconstruction 
therapy  in  many  more  instances,  and  more  rapidly  give 
proofs  of  its  value. 

14 


BIBLIOGRAPHY  OF  OCCUPATIONAL  THERAPY 

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Barton,  George  Edward.  Occupational  Therapy.  Trained 
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Cabot,  Dr.  R.  C.  Work  Cure.  Psychotherapy,  N.  Y.,  1909, 
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Cameron,  Reba  G.  Occupational  Therapy.  Trained  Nurse 
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Cameron,  Reba  G.  In  Defense  of  our  State  Hospitals  and  the 
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Carr,  Ada  M.,  R.  N.  The  Value  of  Occupational  Therapy 
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Gary,  Harold.  Keeping  Employees  Happy.  (Music,  rest  and 
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210 


BIBLIOGRAPHY    OF    OCCUPATIONAL   THERAPY         211 

Dunton,  Win.  Rush,  Jr.  Occupation  as  a  Therapeutic  Measure. 
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Finley,  Dr.  John  H.,  LL.  D.  The  Wisdom  of  Leisure.  The 
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Friedman,  Henry  M.  Occupational  Specialization  in  the 
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Haas,  Louis  J.  A  New  Vocation — Diversional  Occupation. 
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Hall,  Herbert  J.  Work  Cure.  A  Report  of  Five  Years' 
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Hall,  Herbert  J.  Hospital  and  Asylum  Workshops;  Some 
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Hall,  Dr.  Herbert  J.  Occupation  Therapy  in  Organic  Diseases. 
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Hall,  Herbert  J.  Productive  Occupations  in  Charitable 
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Haviland,  C.  Floyd.  Discussion  of  Advantages  of  Occupational 
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Hills,  F.  L.  Work  for  Patients  as  an  Immediate  and  Ultimate 
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Husted,  Mary  Irving.  The  Industrial  Department  at  Clifton 
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Husted,  Mary  Irving.  Industrial  Work  and  the  Value  of  Re- 
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Klopp,  Henry  I.  Is  an  Occupation  Teacher  Desirable?  Trans. 
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Lundh,  K.  Arbejdsterapi  som  led  i  sanatoriebehandligen. 
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Luther,  Jessie.  Industrial  Work.  Among  the  Deep  Sea  Fishers, 
xi,  p.  21,  January,  1914. 


212  RECONSTRUCTION    THERAPY 

Luther,  Jessie.  Industrial  Work.  Among  the  Deep  Sea  Fishers, 
xiii,  p.  3,  April,  1915. 

McMahon,  Miss  Amy.  The  Problem  of  the  Child  in  the 
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70,  1910. 

MacDonald,  Elizabeth  Stone.  Helping  Them  to  Help  Them- 
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Neff,  Mary  Lawson.  The  Use  of  Waste  Materials.  Maryland 
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Oekonomakis.  Ueber  einige  Heilerfolge  der  Arbeitstherapie. 
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1909. 

Occupation  for  Convalescents.  Editorial.  Medical  Record, 
Ixxxiii,  No.  17,  p.  760,  April  26,  1913. 

Smith,  Amy  Armour.  Christmas  for  the  Shut-ins.  Trained 
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"  Something  to  do  " — The  New  Medicine.  The  Survey,  xxxvii, 
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Taber,  Miss  Marion  R.  Handicrafts  for  the  Handicapped. 
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Thayer,  Addison  S.  Work  Cure.  Journal  A.  M.  A.,  li,  pp. 
1485-1487,  October  31,  1908. 

Veraguth,  Otto.  Ueber  Arbeitstherapie.  Therapie  der  Gegen- 
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Upham,  Elizabeth  G.  Some  Principles  of  Occupational 
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Weist,  Anna.  Beschaftigungsbuch  fur  Kranke  und  Rekon- 
valscenten.  Enke.  5  Marks. 

AMUSEMENTS 

Curwen,  Dr.  John.  Amusements  and  Recreations  Best  Adapted 
to  Insane  Hospital  Treatment.  Proceedings  of  15th  meeting  of 
Assoc.  Med.  Supts.  of  Am.  Insts.  for  Insane,  in  American  Journal 
of  Insanity,  17,  p.  67,  Philadelphia,  1860. 

Dunton,  Wm .  Rush,  Jr.  Should  there  be  a  Recreation  Schedule  ? 
Trans.  A.  M-P.  A.,  xxii,  p.  337. 

Games,  Bibliography  of.     The  Playground,  x,  p.  453. 

ATHLETICS 

Channing,  Dr.  Walter.  Physical  Training  of  the  Insane. 
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BIBLIOGRAPHY    OF    OCCUPATIONAL   THERAPY         213 

Wright,  W.  E.  The  Institution  Athletic  Field.  Its  Uses  by 
Patients,  Employees,  and  Especially  by  Visiting  Teams  at  the 
White  Plains  Convalescent  Hospital  of  the  Burke  Foundation. 
The  Modern  Hospital,  viii,  p.  119,  February,  1917. 

BLIND 

Austin,  S.  H.  The  Chicago  Light  House  for  the  Blind.  The 
Needs  and  Welfare  of  the  Blind.  The  Modern  Hospital,  ix,  p.  202, 
September,  1917. 

Williams,  Anna  E.     The  Story  of  the  Light  House.     Ibid. 

Comstock,  Charles  E.  What  the  State  of  Illinois  is  Doing  for 
its  Blind.  The  Modern  Hospital,  ix,  p.  80,  August,  1917. 

Wright,  Lucy.  Vocational  Work  for  the  Blind  in  Massa- 
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CARDIAC 

The  Trade  School  for  Cardiac  Convalescents.  First  Annual 
Report,  July  13- July  14. 

Second  Report  of  the  Trade  School  for  Cardiac  Convalescents. 
July  14- July  16. 

Putman,  Mary  L.  Occupational  Provision  for  One  Type  of  the 
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EFFICIENCY  MOTION  STUDY 

Gilbreth,  Frank  B.,  and  Lillian  M.  What  Scientific  Manage- 
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Gilbreth,  Frank  B.  Graphical  Control  on  the  Exception  Prin- 
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214  RECONSTRUCTION    THERAPY 

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Gilbreth,  Frank  B.  The  Principles  of  Scientific  Management 
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HISTORICAL 

Barrows,  Mary.  Susan  E.  Tracy,  R.  N.  Maryland  Psy- 
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Dunton,  Win.  Rush,  Jr.  History  of  Occupational  Therapy. 
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Eddy,  Thomas.  Communication  to  the  Board  of  Governors. 
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Newton,  Isabel  G.  Consolation  House.  Trained  Nurse  and 
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Parsons,  Sara  E.  Miss  Tracy's  Work  in  General  Hospitals. 
Maryland  Psychiatric  Quarterly,  vi,  p.  63,  January,  1917. 

Slagle,  Eleanor  Clark.  History  of  the  Development  of  Occu- 
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July,  1914. 

White,  William  A.  Critical  Historical  Review.  Reil's  Rhap- 
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HYGIENE 

Oliver  T.  Occupations  from  the  Social,  Hygienic,  and  Medical 
Points  of  View.  Cambridge  University  Press. 

LIBRARIES 

Carey,  Miriam  E.  Libraries  and  Their  Management  in  State 
Hospitals.  The  Modern  Hospital,  vi,  p.  407,  December,  1915. 

Carey,  William  E.  Traveling  Libraries  in  Hospitals.  The 
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BIBLIOGRAPHY   OF   OCCUPATIONAL   THERAPY         215 

Problems    of    Administration.     Proceedings    6th    Alienists    and 
Neurologists  of  America,  180. 

Jones,  Edith  Kathleen.  Libraries  for  the  Patients  in  Hospitals 
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July,  1911. 

Jones,  Edith  Kathleen.  A  Thousand  Books  for  the  Hospital 
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Jones,  Edith  Kathleen.  On  Books  and  Reading.  Outline  of  a 
Course  of  Lectures  for  Nurses  in  Hospitals.  American  Journal 
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Jones,  Edith  Kathleen.  Books  for  the  Hospital  Library.  The 
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Jones,  Edith  Kathleen.  "What  can  I  Find  to  Read  Aloud?" 
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Jones,  Edith  Kathleen.  "Culture  Courses"  in  Training 
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Jones,  Edith  Kathleen.  The  Value  of  the  Library  in  the 
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Jones,  Edith  Kathleen.  State  Control  of  State  Hospital 
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Jones,  Edith  Kathleen.  Library  Work  Among  the  Insane. 
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Jones,  Edith  Kathleen.  Importance  of  Organized  Libraries 
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Jones,  Edith  Kathleen.  The  Hospital  Library — Books  for  the 
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Jones,  Edith  Kathleen.  Hospital  Library  Economics.  Pro- 
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Shellenberger,  Miss  Grace.  Experiments  in  Story  Telling. 
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Williams,  T.  Nellie.  The  Library  from  the  Patient's  Point  of 
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MENTAL 

Allison,  H.  E.  The  Moral  and  Industrial  Management  of  the 
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Anderson,   P.    V.     The    Value   of   Employment   in    Cases   of 


216  RECONSTRUCTION    THERAPY 

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Antonoff,  E.  V.  Physical  Labor  as  a  Means  of  Treating 
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Blumer,  Geo.  A.  The  Medical  and  Material  Aspects  of  In- 
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Browne,  W.  A.  F.  The  Moral  Treatment  of  the  Insane. 
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Buttolph,  H.  A.,  M.  D.  Modern  Asylums  and  their  Adapta- 
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Burnet,  Anne.  Re-education  of  the  Insane.  Bulletin  of  Iowa 
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Cameron,  Reba  G.  Industries  and  Amusements.  Trained 
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Cohn,  Eugen.  The  Systematic  Occupation  and  Entertain- 
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Connolly,  Dr.  John.  The  Treatment  of  the  Insane  Without 
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Cohoon,  E.  H.  The  Therapeutics  of  Industrial  Occupation 
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Donohoe,  Dr.  Geo.  A  Preliminary  Report  of  Kindergarten 
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xxii,  p.  311. 


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Everett,  Edward  A.  The  Treatment  of  Nervous  and  Mental 
Diseases  by  Occupational  Methods.  The  Hahnemannian  Monthly, 
August,  1912. 

Fields,  Grace  E.  The  Effect  of  Occupation  upon  the  Indi- 
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Francis,  L.  Outdoor  Work  as  a  Remedial  Agent  in  Insanity. 
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Frost,  Henry  P.,  M.D.  Occupation  of  Patients.  Trans.  A. 
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Frost,  Henry  P.,  M.D.  Occupation  of  Patients  in  State 
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1915. 

Gilbreth,  Frank  B.  and  Lillian  M.  Measurement  of  the 
Human  Factor  in  Industry.  Read  at  National  Conference  of 
Western  Efficiency  Society,  May  22,  1917. 

Goss,  A.  V.  Occupation  as  a  Remedial  Agent  in  the  Treatment 
of  Mental  Diseases.  American  Journal  of  Insanity,  Ixx,  p.  477, 
October,  1913. 

Gross,  Ellen  Kate.  Occupation  and  Recreation  Classes  for  the 
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Hamlin,  Francis  M.  Schools  for  the  Insane.  American 
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Haviland,  C.  Floyd.  Discussion  on  Occupations  for  the 
Insane  and  their  Therapeutic  Value;  What  is  now  done  and  what, 
if  anything  further  should  be  done.  N.  Y.  State  Hospitals 
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Haviland,  C.  Floyd.  Occupation  for  the  Insane.  Trans. 
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Ixix,  No.  3,  p.  483. 

Herring,  Arthur  P.,  Chairman.  Diversional  Occupation  of  the 
Insane.  Trans.  A.  M-P.  A.,  xix,  pp.  245-248,  1912. 

Hoyt,  Dr.  Frank  Crampton.  Occupation  in  the  Treatment  of 
the  Insane.  Trans.  A.  M-P.  A.,  v,  p.  288.  1898. 

Hutchings,  R.  H.  Demonstration  of  Work  done  by  Patients  in 
Kindergarten.  N.  Y.  State  Hospitals  Bulletin,  May,  1912. 

Haines,  Emily  L.  Occupation  as  a  Remedial  Factor  in  Hos- 
pitals for  the  Mentally  Sick.  Boston  Medical  and  Surgical 
Journal,  cxxiv,  p.  609,  April  27,  1916. 

Jarvis,  Edward.  Mechanical  and  Other  Employments  for 
Patients  in  British  Asylums.  American  Journal  of  Insanity, 
xix,  p.  129,  October,  1862.  Read  before  the  Association  and 
discussed  on  pp.  57-81.  See  also  p.  54,  where  he  discusses  another 
paper. 

Kirkbride,  Thos.  A.,  M.  D.  On  the  Construction,  Organization, 
and  General  Arrangements  of  Hospitals  for  the  Insane  with  some 
Remarks  on  Insanity  and  its  Treatment.  Philadelphia,  1880,  J.  B. 


218  RECONSTRUCTION    THERAPY 

Lippincott  &  Co.  Part  1,  Chap,  liv,  Patient's  Work  Rooms. 
Part  2,  Chap,  xiv,  Companions  or  Teachers.  Part  2,  Chap, 
xxxii,  Labor,  Outdoor  Exercise  and  Amusements.  Part  2,  Chap, 
xxxiii,  Evening  Entertainments. 

LaMoure,  C.  T.,  Rochester,  New  York.  The  Value  of  Sys- 
tematic Teaching  in  Cases  of  Dementia  Prsecox.  Reprinted 
from  the  Alienist  and  Neurologist,  xxxi,  St.  Louis,  August,  1910. 

LaMoure,  Chas.  T.  Re-education  of  Dementia  Prsecox  Cases 
and  Industrial  Training  of  the  Chronic  Cases.  Trans.  A. 
M-P.  A.,  xix,  p.  263,  1912. 

LaMoure,  Charles  T.  Toy  Making  as  an  Occupation  for  the 
Insane.  Maryland  Psychiatric  Quarterly,  iii,  No.  1,  p.  16,  July, 
1913. 

LaMoure,  Chas.  T.  The  Re-education  of  the  Insane.  Mary- 
land Psychiatric  Quarterly,  i,  p.  37,  October,  1911. 

Lindsay,  W.  Lauder.  Reprint  from  the  Report  of  James 
Murray's  Royal  Asylum,  Perth,  Scotland,  for  1860-1.  Maryland 
Psychiatric  Quarterly,  iii,  No.  1,  p.  10,  July,  1913. 

Marie.  Work  in  the  Treatment  of  the  Insane.  Rev.  de 
Psych,  et  de  Psychol.  Exper.,  p.  1,  January,  1906. 

Moher,  Thomas  J.  Occupation  in  the  Treatment  of  the 
Insane.  Jour.  A.  M.  A.,  xlviii,  p.  1664,  May  18,  1907.  Abstract 
in  American  Journal  of  Insanity,  Ixiv,  p.  212,  1907. 

Neff,  Mary  Lawson.  The  Minimizing  of  Insanity.  Journal 
A.  M.  A.,  Ixi,  p.  559,  August  23,  1913. 

Neff,  Mary  Lawson.  Occupation  as  a  Therapeutic  Agent  in 
Insanity.  Medical  Record,  Ixxviii,  December  3,  1910. 

Neff,  Mary  Lawson.  A  Model  Program  for  a  Ward  in  a  State 
Hospital.  Bulletin  of  Iowa  State  Institutions,  July,  1914. 

Neff,  Mary  Lawson.  Successes  and  Failures  in  the  Employment 
of  Occupation  for  the  Treatment  of  the  Insane.  Proceedings 
of  16th  Annual  Convention  of  American  Society  of  Superin- 
tendents of  Training  Schools  for  Nurses,  p.  183,  1910. 

Neff,  Mary  Lawson.  Hilda's  Pillow :  Healing  the  Insane  through 
Work.  The  Craftsman,  xxvii,  p.  99,  October,  1914. 

Neff,  Mary  Lawson.  The  "Institutionalized"  Insane.  The 
Modern  Hospital,  ix,  p.  232,  September,  1917. 

Nickerson,  Mary  A.  A  Plan  for  the  Re-education  of  Dementia 
Praecox  Cases.  Maryland  Psychiatric  Quarterly,  iii,  No.  1, 
p.  7,  July,  1913. 

Parigot,  A.  General  Mental  Therapeutics.  American  Journal 
of  Insanity,  xx,  p.  300,  April,  1863. 

Purdum,  H.  D.  The  Psychotherapeutic  Value  of  Occupation. 
Maryland  Psychiatric  Quarterly,  i,  p.  35,  October,  1911. 

Purdum,  H.  D.  Report  of  the  Re-educational  Work  at  Bay 
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1912. 


BIBLIOGRAPHY    OF    OCCUPATIONAL    THERAPY         219 

Ray,  I.  Labor  in  Principal  Hospitals  for  Insane  in  Great 
Britain,  France  and  Germany.  American  Journal  of  Insanity, 
ii,  p.  359,  1846.  A  part  of  a  paper  entitled  Observations  on  the 
principal  hospitals  for  the  insane  in  Great  Britain,  France  and 
Germany.  A  section  on  amusements  and  recreations,  and 
another  on  schools,  follows. 

Ray,  I.  The  Labor  Question  and  Hospitals  for  Incurables. 
American  Journal  of  Insanity,  xxii,  p.  439,  1866.  Reprinted 
from  Report  to  Corporation  of  Butler  Hospital  for  1865. 

Reid,  Eva  Charlotte,  M.D.,  San  Francisco.  Ergotherapy  in  the 
Treatment  of  Mental  Disorders.  Boston  Medical  and  Surgical 
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Ricksher,  Charles.  Occupation  in  Treatment  of  Insane. 
Illinois  Medical  Journal,  April,  1913. 

-  Ripley,  Dr.  Horace  G.  Should  Occupation  be  Limited  to 
Work  Rooms,  or  Distributed  about  the  Wards?  Trans.  A. 
M-P.  A.,  xxii,  p.  335. 

Robinson,  Dr.  Leigh  F.  Diversional  Therapy  in  Mental 
Disease.  A  plan  for  its  employment  with  special  reference  to 
social  clubs.  Medical  Record,  December  9,  1916. 

Rossy,  C.  S.  The  Feeble-minded  in  Industry.  The  Modern 
Hospital,  ix,  p.  204,  September,  1917. 

Russell,  William  L.  Diversional  Occupations  and  Physical 
Exercises  as  Remedial  Measures  at  Bloomingdale  Hospital. 
General  Bulletin  of  the  Society  of  the  New  York  Hospital,  i, 
No.  5,  December  24,  1915. 

Sanborn,  B.  T.  Employment  of  the  Insane.  Trans.  Maine 
Medical  Ass.,  Portland,  pp.  211-220,  1887. 

Sawyer,  Dr.  Carl  W.  Occupation  for  Mental  Cases  during 
Institutional  Care.  The  Modern  Hospital,  ii,  p.  85,  August,  1915. 

Singer,  H.  Douglas.  A  Modern  Hospital  for  the  Insane  from 
the  Standpoint  of  Medical  Service — Research  and  Educational 
Work.  The  Institution  Quarterly,  viii,  p.  92,  March  31,  1917. 

Stedman,  Henry  R.,  M.D.  The  Art  of  Companionship  in 
Mental  Nursing.  Boston  Medical  and  Surgical  Journal,  clxx,  p. 
673,  April  30,  1914. 

Stekmann.  Arbeit  als  Kurmittel  in  Psycho theripie.  Mtinchen. 
Med.  Wochenschr.,  Ivi,  p.  943,  1909. 

Tomlinson,  H.  A.  The  Influence  of  Occupation  in  the  Pre- 
vention of  Mental  Reduction.  Minnesota  Quarterly,  p.  39,  Novem- 
ber, 1907. 

Tuke,  Dr.  D.  Hack.  Reform  in  the  Treatment  of  the  Insane. 
London,  1892.  J.  and  A.  Churchill,  pp.  35  and  52. 

Van  Nuys,  J.  D.  The  Value  of  Occupation  in  the  Treatment 
of  the  Insane.  Sixth  Semi-annual  Bull,  of  Kansas  State  Charitable 
Institutions,  February,  1911. 


220  RECONSTRUCTION    THERAPY 

Wade,  J.  Percy.  Occupation  of  the  Insane.  Maryland 
Psychiatric  Quarterly,  i,  p.  1,  No.  1,  p.  10,  July,  1911. 

Wade,  J.  Percy.  Remarks  on  Occupation  of  the  Insane. 
Maryland  Hospital  News,  November,  1908. 

Wardner,  Horace,  M.  D.  Occupation  in  Treatment  of  In- 
sanity. Tr.  ix  Internat.  M.  Cong.,  Wash.,  1887,  v,  pp.  273-278. 
Also  Alienist  and  Neurol.,  ix,  pp.  227-236,  1888. 

Winterode,  Robert  P.  Remedial,  Economic  and  Ethical 
Value  of  Employment  of  Patients  as  Utilized  in  State  Hospitals. 
Maryland  Medical  Journal,  Ixii,  p.  331,  October,  1910. 

Winterode,  Robert  P.  Shop  Occupation.  Various  Methods 
of  Employing  Women.  Second  biennial  report  of  Crownsville 
State  Hospital. 

Zeller,  G.  A.  More  Work  and  Recreation  for  the  Chronic 
Insane.  Kansas  City  Medical  Index-Lancet,  October,  1910. 

NEUROLOGICAL 

Everett,  Edward  A.,  M.  D.  The  Treatment  of  Nervous  and 
Mental  Diseases  by  Occupational  Methods.  The  Hahnemannian 
Monthly,  August,  1912. 

Cabot,  Richard  C.     The  Dangers  of  Rest.     Good  Housekeeping. 

Geissler,  G.  Bedeutung  und  Wert  der  Arbeitshandlung 
Nervenkranken.  Muench.  Med.  Woch.,  liii,  No.  21,  Abs.  Journal 
A.  M.  A.,  xlv,  p.  431,  August  5,  1905. 

Hall,  Herbert  J.  The  Systematic  Use  of  Work  as  a  Remedy 
in  Neurasthenia  and  Allied  Conditions.  Boston  Medical  and 
Surgical  Journal,  January,  1905. 

Hall,  Herbert  J.  Neurasthenia.  A  Study  of  Etiology.  Treat- 
ment by  Occupation.  Boston  Medical  and  Surgical  Journal, 
cliii,  July  13,  1905. 

Hall,  Dr.  Herbert  J.  Manual  Work  as  a  Remedy.  Proceedings 
of  16th  Annual  Convention  of  American  Society  of  Superin- 
tendents of  Training  Schools  for  Nurses,  p.  196,  1910. 

Hall,  Herbert  J.  Manual  Work  in  the  Treatment  of  Functional 
Nervous  Diseases.  Journal  A.  M.  A.,  Iv,  No.  4,  p.  295,  July  23, 
1910. 

Jolly,  P.  Occupation  Therapy  for  Soldiers  with  Nervous 
Affections.  Med.  Wochenschr.,  xlii,  p.  1514,  December  7,  1916. 

Paidoleau,  A.  De  la  Medicine  Morale  dans  le  traitement  des 
Maladies  Nerveuses.  Paris,  1864. 

Schwab,  Sidney  I.  Therapeutic  Value  of  Work  in  Hysteria 
and  Neurasthenia.  Interstate  Medical  Journal,  ix,  May,  1902. 

Williams,  Tom  A.  Occupational  Neurosis,  Pathogenesis  and 
Examples  of  Treatment.  Cleveland  Medical  Journal,  xiii,  p.  447, 
July,  1914. 


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OUTDOORS 

Bower,  D.  Treatment  by  Occupation  in  an  English  Private 
Asylum.  Tr.  ix  Internat.  M.  Cong.  Wash.,  v,  pp.  279-281,  1887. 

Carlisle,  Chester  L.  A  Graded  and  Systematized  Plan  of 
Outdoor  Exercise  for  the  Demented  Insane.  American  Journal 
of  Insanity,  lix,  p.  637. 

Carroll,  Robert  S.  The  Therapy  of  Work.  Journal  A.  M.  A., 
liv,  No.  25,  p.  2032,  June  13,  1910. 

Hooker,  Elizabeth  Robbins.  Lock  and  Key.  A  Plea  for 
Flower  Distribution  in  Hospital  Wards  and  Garden  Work.  The 
Survey,  April  7,  1917. 

Jacoby,  G.  W.  A  Colony  Sanatorium  for  the  Nervous  and 
Neurasthenic.  A  Much  Needed  Work  of  Philanthropy.  New 
York  Medical  Journal,  Ixxxvii,  p.  719,  April  18,  1908. 

Love,  Geo.  R.  Farm  Work  Best  Occupation  for  the  Insane. 
Effect  on  Patient  and  Value  of  Products  to  be  Considered.  How 
to  Organize  Patient  Labor  in  State  Institutions.  Hospital  Man- 
agement, ii,  p.  14,  August,  1916. 

REWARDS 

Brown,  W.  A.  F.  On  Rewarding  and  Employing  Patients. 
Journal  of  Mental  Science,  xxix,  April,  1883. 

Smith,  S.  Compensation  of  Insane  Labor,  Suggestions  in 
Regard  to  the  Better  Organization  of  a  System  of  Labor  for  the 
Chronic  Insane.  Proc.  Confer.  Char.,  1884,  Boston,  pp.  222-228, 
1885. 

Thompson,  Charles  E.  Should  Patients  be  Rewarded  for 
Industrial  Occupation.  Trans.  A.  M-P.  A.,  xxii,  p.  327. 

TRAINING  COURSES 

Columbia  University.  Course  in  Occupation  Therapy.  Sum- 
mer, 1917. 

Cottle,  Jennie.  Can  the  Study  of  Current  Events  be  Made  the 
Means  of  Recreation  for  Pupil  Nurses?  10th  report  of  American 
Association  of  Superintendents  of  Training  Schools  for  Nurses, 
p.  19,  1903.  In  favor  but  acknowledges  the  difficulties. 

Delano,  Jane.  Can  the  Study  of  Current  Events  be  Made  the 
Means  of  Recreation  for  Pupil  Nurses.  10th  report  of  American 
Association  of  Superintendents  of  Training  Schools  for  Nurses, 
p.  17,  1903.  Is  opposed. 

Dunton,  Wm.  Rush,  Jr.  A  Nurse's  Occupation  Course. 
Trans.  Am.  Medico-Psychol.  Assoc.,  xix,  p.  269,  1912. 

Giles,  Ida  F.  The  Principles  of  Scientific  Management  Ap- 
plied to  Wards  and  Other  Departments  of  Hospitals.  18th 


222  RECONSTRUCTION    THERAPY 

Report  of  American  Association  Superintendents  of  Training 
Schools  for  Nurses,  p.  103,  1912. 

Lawler,  E.  M.  How  much  Time  should  be  Allowed  for  Special- 
ism During  the  Training  School  Course?  22d  Report  of  American 
Association  of  Superintendents  of  Training  Schools  for  Nurses, 
p.  127,  1916. 

Morris,  Geo.  M.  Wentworth  Institute.  Its  Part  in  Training 
Army  Engineers.  Manual  Training  Magazine,  xix,  p.  4,  Septem- 
ber, 1917. 

Snyder,  Edwin  R.  The  Vocational  Trend  in  Education. 
21st  Report  of  American  Association  Superintendents  of  Training 
Schools  for  Nurses,  p.  99,  1915. 

Stewart,  Isabel  M.  Apprenticeship  as  a  Method  of  Vocational 
Education.  17th  Report  of  Am.  Assoc.  Supts.  of  Training  Schools 
for  Nurses,  p.  182,  1911. 

Taylor,  Erne  J.  Why  does  the  Nurse  in  the  General  Hospital 
Need  Training  for  Mental  Work?  22d  Report  of  Am.  Assoc.  of 
Supts.  of  Training  Schools  for  Nurses,  p.  195,  1916. 

Tracy,  Susan  E.  The  Training  of  the  Nurse  as  an  Instructor 
in  Invalid  Occupations.  Proceedings  of  16th  Annual  Convention 
of  American  Society  of  Superintendents  of  Training  Schools  for 
Nurses,  178,  p.  1910. 

TUBERCULOSIS 

The  Care  of  the  Jewish  Tuberculous.  N.  Y.  Committee 
Report,  1916. 

Barton,  George  Edward.  Occupation  and  Auto-inoculation 
in  Tuberculosis.  The  Trained  Nurse  and  Hospital  Review,  Sep- 
tember and  October,  1916. 

Brown,  Philip  King,  M.  D.  The  Potteries  of  Arequipa  Sana- 
torium. Reprinted  from  The  Modern  Hospital,  viii,  No.  6,  June, 
1917. 

•  Dumarest,  Dr.  F.,  et  Dr.  A.  Vigne.  Organization  et  mise  en 
oevre  d'une  cure  de  travail  dans  un  sanatorium  populaire.  Paris 
Medicale,  vi,  No.  30,  1916.  Abs.  Modern  Hospital,  ix,  142, 
August,  1917.  This  institution  was  established  in  Hauteville 
in  1909.  It  is  carried  on  as  is  the  Frimley  Hospital  under  Dr. 
Marcus  Paterson. 

Pamenne.  Le  travail  manuel  agent  de  therapeutique  phy- 
sique. J.  de  physiotherap.  Paris,  1910,  viii,  551-558.  Also, 
Cong,  internat.  de  physiotherap.  Compte  rendu,  1910,  Paris, 
iii,  p.  310,  1911. 

|k  Farrand,  Dr.  Livingston.  Occupation  in  Relation  to  Tuber- 
culosis. Proceedings  of  16th  Annual  Convention  of  American 
Society  of  Superintendents  of  Training  Schools  for  Nurses,  p.  201, 
1910. 


BIBLIOGRAPHY    OF    OCCUPATIONAL    THERAPY         223 

Ford,  James  S.,  M.  D.  The  Employment  of  Persons  in  the 
Arrested  Stage  of  Tuberculosis.  Medical  Record,  xc,  p.  1154, 
December  30,  1916. 

Stein,  Fred.  M.  Family  Care  of  the  Tuberculous.  Journal 
of  the  Outdoor  Life,  xiv,  p.  135,  May,  1917. 

Hochhauser,  Edward.  Home  Treatment  for  the  Tuberculous, 
Garment  Workers  Shop.  The  Modern  Hospital,  viii,  March,  1917. 

SUGGESTIVE  REFERENCE  BOOKS 

Baker,  Ray  S.  New  Ideals  in  Healing.  N.  Y.,  1909,  F.  A. 
Stokes  Co. 

Barrus,  Clara.  Nursing  the  Insane.  Chapters  on  Amuse- 
ments and  Occupations. 

Barton,  George  Edward.  Reconstruction.  N.  Y.,  1918, 
Macmillan  Co. 

Beers,  Clifford.     The  Mind  that  Found  Itself. 

Cabot,  R.  C.     What  Men  Live  By. 

Cannon,  I.  M.  Social  Work  in  Hospitals.  Chapter  on  Medical 
Social  Problems.  N.  Y.,  1913,  Survey  Associates. 

Gulick,  L.  Mind  and  Work.  Chapters:  Handicaps;  The 
Spirit  of  the  Game. 

Gulick,  Luther  M.  The  Efficient  Life.  N.  Y.,  1907,  Double- 
day,  Page  &  Co. 

Partridge,  C.  E.  The  Nervous  Life.  Chapters  on  Recreation; 
Work;  The  Individual. 

Musgrove,  Charles  David.  Nervous  Breakdowns  and  How 
to  Avoid  Them.  Chapter:  Hobbies,  etc.  N.  Y.,  1914,  Funk  & 
Wagnalls  Co. 

Wittmer,  L.  The  Special  Class  for  Backward  Children. 
Chapters  V  and  VI. 

The  only  books,  as  yet  published,  especially  on  occupation 
are: 

Invalid  Occupation,  by  Susan  E.  Tracy.  Boston,  Whitcomb  & 
Barrows.  $1.50. 

The  Work  of  Our  Hands,  by  Herbert  J.  Hall,  and  Mertice  M.  C. 
Buck.  New  York,  Moffatt,  Yard  &  Co.  $1.50. 

Handicrafts  for  the  Handicapped,  by  the  same.  Same  pub- 
lishers. 

Occupational  Therapy  by  George  Edward  Barton,  N.  Y., 
1916,  Lakeside  Publishing  Co.  30  cents. 

Re-education.  An  Analysis  of  the  Institutional  System  of  the 
U.  S.,  by  George  Edward  Barton,  A.  I.  A.  Houghton,  Mifflin  Co. 

Occupation  Therapy.  A  Manual  for  Nurses,  by  W.  R.  Dun- 
ton,  Jr.  Philadelphia,  W.  B.  Saunders  Company.  $1.50. 


224  RECONSTRUCTION    THERAPY 

AN  ABRIDGED  BIBLIOGRAPHY  OF  CRAFT  BOOKS 
BASKETRY 

Ashley,  Gertrude  and  Millicent.  Raffia  Basketry  as  a  Fine 
Art.  Mrs.  Gertrude  P.  Ashley,  Deerfield,  Mass.  $2.00. 

Blanchard,  Mary  Miles.  The  Basket  Book.  N.  Y.,  1914, 
Chas.  Scribner's  Sons.  $2.00. 

Firth.  Cane  Basket  Work.  Part  I,  65  cents.  Part  II,  65  cents. 
London,  T.  Upcott  Gill,  1899. 

James,  G.  W.     Practical  Basket  Making.     $1.25. 

James,  G.  W.  Indian  Basketry  and  How  to  Make  Indian  and 
Other  Baskets.  $2.50. 

James,  G.  W.     How  to  Make  Indian  and  Other  Baskets.     $1.00. 

Marten,  William.  S.  Inexpensive  Basketry.  Peoria,  111., 
The  Manual  Arts  Press.  25  cents. 

Hasluck,  Paul  N.     Basket  Work.     Cassell  &  Co.     50  cents. 

Turner,  Luther  W.  The  Basket  Maker.  Worcester,  Mass., 
1909,  The  Davis  Press.  $1.00. 

White,  Mary.  How  to  Make  Baskets.  N.  Y.,  Doubleday,  Page 
&  Co.  $1.00. 

Ibid.     More  Baskets  and  How  to  Make  Them.     $1.00. 

BOOKMAKING 

Cockerell,  Douglas.  Bookbinding  and  the  Care  of  Books. 
Appleton.  Artistic  crafts  series  of  technical  handbooks.  $1.25. 

Freeman,  S.  T.  A  Syllabus  of  Elementary  Bookbinding 
(Teachers'  College,  Columbia).  30  cents. 

Hasluck,  Paul  N.     Bookbinding.     Cassell  &  Co.     50  cents. 

PAPER  WORK 

Buxton  and  Curran.  Paper  and  Cardboard  Construction. 
$1.50. 

Rich.     Paper  Sloyd.   .75  cents. 

Wuest,  Esther  W.  Development  of  Design  Through  Paper 
Cutting.  Portland,  Oregon,  published  by  author.  36  pp. 

CORD  WORK 

Hasluck,  Paul  N.  Knotting  and  Tying.  Phila.,  1903,  David 
McKay,  1022  Market  St.  N.  Y.  and  London,  Cassell. 

McCormack,  Mary  A.     Spool  Knitting.     $1.00. 

Walker,  Louisa.     Varied  Occupations  in  String  Work.     $1.25. 

Miller,  Katherine  E.  Abnakee  Rug-making  as  a  Village 
Industry.  The  House  Beautiful,  x,  p.  287,  October,  1901. 

Verrill.  Knots,  Splices  and  Rope  Work.  Norman  W.  Henley, 
132  Nassau  St.,  N.  Y.  60  cents. 


BIBLIOGRAPHY    OF    OCCUPATIONAL   THERAPY         225 

PHYSICAL  EXERCISES 

Cromie,  William  J.  Keeping  Physically  Fit.  Macmillan 
Co.,  1916.  $1.00. 

Bancroft,  Jessie  H.  and  Dean  Pulvermacher.  Athletic  Games 
for  Players.  Macmillan  Co.,  1916.  $1.50. 

Ochsner,  Edward  H.,  M.  D.  Physical  Exercises  for  Invalids 
and  Convalescents.  St.  Louis,  C.  V.  Mosby  Co.,  1917.  75  cents. 

GAMES,  ETC. 

Cotman  and  Kohler.  Swedish  Song  Games.  Ginn  &  Co., 
1913. 

Curtis.     Education  Through  Play.     Macmillan  Co.,  N.  Y. 
Lee,  Joseph.     Play  in  Education.     Macmillan  Co.,  N.  Y. 

KNITTING  AND  CROCHETING 

Columbia  Book  of  Yarns. 
Fleisher  Book  of  Yarns. 

LEATHER  WORK 

Leather  Work.  Adelaide  Michel.  The  Manual  Arts  Press. 
75  cents. 

METAL 

Haas,  Louis  J.  Art  Metal  Work  and  Jewelry.  Sequoyah 
Publishing  Co.,  Oswego,  N.  Y.  $1.00. 

Rose.     Copper  Work.     Worcester,  The  Davis  Press.     $1.50. 

Rose  and  Cirino.  Jewelry  Making  and  Design.  Providence, 
Metal  Crafts  Publishing  Co.  $5.00. 

Sleffel,  Charles  Conrad.  Working  in  Metals.  Doubleday, 
Page  &  Co.  Library  of  Work  and  Play. 

Wilson  H.  Silverwork  and  Jewelry.  Macmillan  Co.  Artistic 
crafts  series  of  technical  handbooks. 

NEEDLEWORK 

Archer,  Erne  Archer.  Needlecraft.  Doubleday,  Page  &  Co. 
Library  of  Work  and  Play. 

Christie,  Mrs.  A.  H.  Embroidery  and  Tapestry  Weaving. 
Macmillan  Co.  Artistic  crafts  series  of  technical  handbooks. 

Klickman,  Flora.  The  Home  Art  Book  of  Fancy  Stitchery. 
Stokes  Co. 

Priscilla  cross-stitch  book.  Priscilla  colored  cross-stitch  book. 
No.  1  and  No.  2,  each  25  cents. 

15 


226  RECONSTRUCTION    THERAPY 

PLASTIC  ARTS 

Binns,  F.     The  Potter's  Craft.     $2.00. 

Davidson,  R.  C.  Concrete  Pottery  and  Garden  Furniture. 
$1.50. 

TYPOGRAPHY 

George  E.  McClellan.     Practical  Typography.     $1.50. 
WEAVING 

Hall,  Eliza  Calvert.  A  Book  of  Hand-woven  Coverlets, 
Boston,  1912,  Little,  Brown  &  Co. 

Hooper,  Luther.  Hand  Loom  Weaving,  Plain  and  Orna- 
mental. Macmillan  Co.  Artistic  crafts  series  of  technical 
handbooks. 

Worst,  Edward  F.  Foot-Power  Loom  Weaving.  Bruce  Pub- 
lishing Co.  $3.50. 

WOOD  WORK 

James  Thomas  Baily  and  S.  Pollitt.  Wood  Work  for  Schools. 
A  collection  of  120  practical  problems,  many  of  which  have  been 
designed  to  correlate  mathematics  and  physical  science  with 
manual  training.  75  cents. 

Griffith.  Correlated  Course  in  Wood  Work  and  Mechanical 
Drawing.  $1.50. 

Jack,  George.     Wood  Carving.     $1.40. 

Johnson,  Ben  W.     Coping  Saw  Work.     20  cents. 

Larsson.     Elementary  Sloyd  and  Whittling.     75  cents. 

Richardson.     Elementary  Knife  Work.     25  cents. 

Richardson,  Advanced  Knife  Work.     25  cents. 

Moore,  H.  W.  Manual  Training  Toys  for  the  Boys'  Work- 
shop. $1.00. 

DRAWING 

Evans,  F.  H.  The  Drafting  Room  Series  in  3  Volumes.  Part 
I.  Reading  Machine  Drawings.  Part  II.  Machine  Drafting. 
Part  III.  Interference  of  Moving  Parts  and  Tooth  Gears.  90 
cents  or  65  cents. 

Johnston,  Edward.  Writing  and  Illuminating  and  Lettering. 
Macmillan  Co.  Artistic  crafts  series  of  technical  handbooks. 
$2.00. 

Miller,  H.  W.     Mechanical  Drafting.     50  cents. 

Stevens,  Thomas  Wood.  Lettering.  Prang  Co.  Large  Quarto, 
$2.00. 

For  the  development  of  a  knowledge  of  form  and  color  probably 
nothing  better  can  be  obtained  than  the  series  of  Industrial  Art 
Textbooks  written  by  Bonnie  E.  Snow  and  Hugo  E.  Froelicher, 
which  are  published  by  Prang  and  Co.  These  are  published  in 
eight  parts,  arranged  for  the  different  school  grades,  and  are 
most  practical  and  suggestive. 


APPENDIX* 


At  the  recent  meeting  of  the  National  Society  for  the 
Promotion  of  Occupational  Therapy,  Dr.  Dimton  read 
a  paper  upon  the  Principles  of  Occupational  Therapy, 
in  which  he  suggested  that  the  society  formulate  funda- 
mental principles  for  the  guidance  of  those  inexperienced 
in  this  work. 

He  offered  a  number  of  suggestions,  based  upon  his 
rules  for  the  guidance  of  nurses  which  might  be  used  as 
a  nucleus  for  the  consideration  of  a  committee  which  was 
appointed  to  bring  in  a  report  upon  this  important  matter. 
This  committee,  consisting  of  Mrs.  Slagle,  Dr.  W.  L. 
Russell,  and  Mr.  Burnette,  was  unable  to  reach  any  con- 
clusions before  the  close  of  the  meeting  and  their  report 
is  therefore  published  below: 

To  the  members  of  the  National  Society  for  the  Pro- 
motion of  Occupational  Therapy: 

Your  Committee  on  Principles  has  agreed  upon  the 
following  as  representing  the  basic  principles  of  occupa- 
tional therapy: 

1.  Occupational  therapy  is  a  method  of  treating  the 
sick  or  injured  by  means  of  instruction  and  employment 
in  productive  occupation. 

2.  The  objects  sought  are  to  arouse  interest,  courage, 
and  confidence;  to  exercise  mind  and  body  in  healthy 
activity;  to  overcome  functional  disability;  and  to  re- 
establish  capacity  for  industrial  and  social  usefulness. 

3.  In  applying  occupational  therapy,  system  and  pre- 
cision are  as  important  as  in  other  forms  of  treatment. 

*From  the  Maryland  Psychiatric  Quarterly,  January,  1919. 

227 


228  APPENDIX 

4.  The  treatment  should  be  administered  under  con- 
stant medical  advice  and  supervision,  and  correlated  with 
the  other  treatment  of  the  patient. 

5.  The  treatment  should,  in  each  case,  be  specifically 
directed  to  the  individual  needs. 

6.  Though  some  patients  do  best  alone,  employment 
in  groups  is  usually  advisable  because  it  provides  exer- 
cise in  social  adaptation  and  the  stimulating  influence 
of  example  and  comment. 

7.  The  occupation  selected  should  be  within  the  range 
of  the  patient's  estimated  interests  and  capability. 

8.  As  the  patient's  strength  and  capability  increase, 
the  type  and  extent  of  occupation  should  be  regulated 
and  graded  accordingly. 

9.  The  only  reliable  measure  of  the  value  of  the  treat- 
ment is  the  effect  on  the  patient. 

10.  Inferior  workmanship,  or  employment  in  an  occu- 
pation which  would  be  trivial  for  the  healthy,  may  be 
attended  with  the  greatest  benefit  to  the  sick  or  injured. 
Standards  worthy  of  entirely  normal  persons  must  be 
maintained  for  proper  mental  stimulation. 

11.  The  production  of  a  well-made,  useful,  and  at- 
tractive article,  or  the  accomplishment  of  a  useful  task, 
requires  healthy  exercise  of  mind  and  body,  gives  the 
greatest  satisfaction,  and  thus  produces  the  most  bene- 
ficial effects. 

12.  Novelty,  variety,  individuality,  and  utility  of  the 
products  enhance  the  value  of  an  occupation  as  a  treat- 
ment measure. 

13.  Quality,  quantity,  and  salability  of  the  products 
may  prove  beneficial  by  satisfying  and   stimulating  the 
patient  but  should  never  be  permitted  to  obscure  the 
main  purpose. 

14.  Good  craftsmanship,  and  ability  to  instruct  are 
essential    qualifications    in    the  occupational  therapist; 
understanding,  sincere  interest  in  the  patient,  and  an 
optimistic,    cheerful   outlook   and   manner   are   equally 
essential. 


APPENDIX  229 

15.  Patients  under  treatment  by  means  of  occupational 
therapy  should  also  engage  in  recreational  or  play  ac- 
tivities. It  is  advisable  that  gymnastics  and  calisthen- 
ics, which  may  be  given  for  habit  training,  should  be 
regarded  as  work.  Social  dancing  and  all  recreational 
and  play  activities  should  be  under  the  definite  head 
of  recreations. 

For  comparison,  we  print  also  the  briefer  principles 
as  suggested  by  Dr.  Dunton  in  his  paper: 

1.  That  work  should  be  carried  on  with  cure  as  the 
main  object. 

2.  The  work  must  be  interesting. 

3.  The  patient  should  be  carefully  studied. 

4.  That  one  form  of  occupation  should  not  be  carried 
to  the  point  of  fatigue. 

5.  That  it  should  have  some  useful  end. 

6.  That  it  preferably  should  lead  to  an  increase  in  the 
patient's  knowledge. 

7.  That  it  should  be  carried  on  with  others. 

8.  That  all  possible  encouragement  should  be  given 
the  worker. 

9.  That  work  resulting  in  a  poor  or  useless  product  is 
better  than  idleness. 

It  is  hoped  that  with  the  above  for  guidance,  the  nu- 
merous students  now  studying  to  assist  in  the  reconstruc- 
tion of  crippled  soldiers  and  sailors  will  more  easily 
acquire  a  knowledge  of  occupational  therapy. 


INDEX 


Accomplishment  card,  85 
Amar,  Dr.  Jules,  107,  131,  137 
Amputated  stump,  treatment  of, 

159 
Amputations,  hip,  tilting  table 

for,  152 

Amusement  director,  39 
Amusements,  44,  89 
Apparatus,  Zander,  165 
Appendix,  227 
Appliances,  prosthetic,  126 
Application  of  occupation,  rules 

for,  56 
Artificial  arms,  131 

legs,  127 

lighting,  98 

Asylum,  James  Murray's  Royal, 
24 

Williamsburg,  22 
Ataxia,  exercises  for,  166 
Atherton,  Miss  Sarah,  119 
Athletic  director,  39 
Athletics,  field  and  track,  95 
Aversa,  24 


i   Bell,  Dr.,  21 

Bibliography    of    occupational 
therapy,  210 

Bielsalski,  Dr.  Konrad,  108 

Blind,  the,  27 
mental  attitude  of,  188 
occupational  therapy  for,  187 

Bloomingdale  Hospital,  98,  100, 
102,  104 

Blumer,  Dr.  G.  Alder,  79 

Board  for  Vocational  Rehabili- 
tation, 123 

Boring,  Edwin  G.,  30,  33,  205 

Bourillon,  Dr.,  107 

Braille,  191 

Butler  Hospital,  22,  79 


C 


B 


Baker,  Mr.  Newton  D.,  121 
Barr,  Dr.  Martin  W.,  184 
Barton,    Mr.   George   Edward, 

108,  204 
Baseball,  93 
Basket  ball,  94 
Bazaar,  75 
Beauty,  definition  of,  54 


Calmady,  Sir  Richard,  158 
Cameron,  Miss  Reba  G.,  86,  88 
Canadian    Military    Hospitals 

Commission,  108 
Cardiacs,  29 
Charenton,  24 
Chicago  School  of  Civics  and 

Philanthropy,  119 
Chores,  42 
Civil  War,  27 
Collie,  Sir  John,  208 
Collins,  Miss  Evelyn  L.,  88 
i   Colors,  use  of,  96 
Companionship,  78,  84,  85 
Conferences,  58 
Conolly,  Sir  James,  21 
Consolation  House,  108 
Corley,  Judge  Quentin  D.,  152 
231 


232 


INDEX 


Council  of  Defense,  113 

Cricket,  94 

Cripples,    German    Association 

for  Care  of,  108 
Croquet,  94 
Crutches,  146 
Culture  courses,  84 
Cummings,  Dr.  John,  121,  124 

D 

Dam,  Dr.,  107 

Dancing,  eurythmic,  162 
folk,  162 

Davis,  19 

Deltenre,  Dr.  Armand,  107 

Dementia  praecox,  habit  forma- 
tion in,  30,  33 

Department  of  Military  Ortho- 
pedic Surgery,  109,  123 

Devereux  Mansion,  102 

Dickens,  137 

Dramatics,  91 

Du  Maurier,  47 

Duties  of  an  occupation  direc- 
tor, 55 

Duty  chart,  39 

E 

Economic  factor,  26 
Eddy,  Mr.  Thomas,  20 
Education,  physical,  162 

revocational,  44 

vocational,  44 

Egypt,  mental  treatment  in,  20 
Electrotherapy,  112 
Empiricism,  207 
Esprit  de  corps,  41,  92 
Esquirol,  22,  24 
Eurythmic  dancing,  162 
Evans,  Dr.  John,  23 


Falret,  19,  23 
Fanner,  40 
Fatigue,  30,  56 
elimination,  150 


Federal  Board  of  Vocational 
Education,  118,  121,  123 

Feebleminded,  occupations  for, 
182 

Feet  exercises,  179 

Field  and  track  athletics,  95 

Filing  method,  71 

Financial,  74 

Finley,  Dr.  John  H.,  49 

Folk  dancing,  162 

Fox,  R.  Fortescue,  165,  178 

Frank,  24 

Franklin  Union,  123 

Franz,  Dr.  Shepherd  Ivory,  28, 
34,  118,  166,  172,  205 

Frenkel,  Dr.  H.  S.,  166,  173 

Friends'  Asylum,  25 


G 


Galen,  18 

Gait,  Dr.  John  M.,  22 

Games,  81,  94,  163 

Cassette,  Miss  Grace,  161 

General  hospital,  67 

German  Association  for  Care  of 

Cripples,  108 
Gilbreth,  F.  B.,  30,   106,   107, 

119,  150 
Golf,  94 

Government  Hospital,  30 
Great  War,  28,  51,  56,  106 
Grenfell,  Dr.  Wilfred,  174 
Guislain,  24 
Gymnastics,  175 


Haas,  Mr.  Louis  J.,  102 
Habit   formation  in   dementia 

praecox,  30,  33 
Haccourt,  Major,  107 
Hall,  Dr.  Herbert  J.,  102,  204 
Hall,  Dr.  Robert  G.,  148 
Heart,  soldier's,  178 
Helps,  69 


INDEX 


233 


Henry  B.  Favill  School  of  Occu- 
pations, 119 
Henry   Phipps   Psychiatric 

Clinic,  67 

Herriot,  Monsieur,  107 
Hip  amputations,  tilting  tables 

for,  152 

Hippocrates,  18 
Holiday  colors,  96 
Hollingsworth,  Prof.  Harry  L., 

37 

Holmes,  Edmond,  182 
Home  service,  201 
Hospital,  general,  67 

Government,  30 

incorporated,  64,  83 

Iowa  State,  25 

Massachusetts  General,  68 

McLean,  21,  25 

Michael  Reese,  68 

New  Jersey  State,  102 

New  York,  20 

Pennsylvania,  25 

Presbyterian  of  Chicago,  68 

Sheppard  and  Enoch  Pratt, 
45,  81 

State,  59 

Taunton  State,  62 
*ITtica  State,  98 
House  of  Recovery,  111 
How  to  live,  48 

Hoyt,  Dr.  Frank  Crampton,  25 
Hydrotherapy,  18,  112,  118,  176 


Incorporated  hospitals,  64,  83 

Industries,  60 

Insanity,  moral  treatment  of,  18 

Instincts,  182 

Interest,  32 

Introduction,  17 

Invalid  occupation,  114 

definition  of,  43 
Iowa  State  Hospital,  25 
Ireland,  Dr.  William  W.,  185 


Jacoby,   Dr.    George   W.,    182, 

183 
James  Murray's  Royal  Asylum, 

24 

Javal,  Dr.  Emile,  190 
Jones,  Miss  Edith  Kathleen,  44, 

84 

K 

Kent,  Miss  Helen  Grace,  30,  35 
Kidner,  Mr.  Thos.  B.,  108 
Kinesitherapy,  51 
Kirkbride,  Dr.  Thos.,  23 
Knee  writing,  181 


Laundryman,  40 
Layton,  Philip  E.,  190 
Lectures,  92 
Legs,  artificial,  127 
Leisure,  The  Wisdom  of,  49 
Librarian,  39 
Library,  value  of,  44,  66 
Life,  normal,  definition  of,  46 
Lighting,  artificial,  98 
Lindsay,  Dr.  W.  Lauder,  24 
Little,  E.  Muirhead,  150,  160 

M 

Maloney,  Dr.  W.  J.  M.  A.,  28, 

118,  166 
Maryland  State  Hospitals  Sale, 

76 

Massachusetts  General  Hospi- 
tal, 68 

Matilda  Ziegler  Magazine,  191 
McKenzie,  Major  R.  Tait,  174 
McLean  Hospital,  21,  25 
McMurtrie,    Mr.    Douglas   C., 

123,  125 
Mental  attitude  of  the  blind, 

188 
treatment  in  Egypt,  20 


234 


INDEX 


Menus,  96 

Method  of  filing  notes,  71 
Michael  Reese  Hospital,  68 
Milbank,  Mr.  Jeremiah,  123 
Military  Hospitals  Commission, 

108 

Orthopedic  Surgery,  Depart- 
ment of,  109,  123 
Miller,  Dr.  H.  Crichton,  113 
Model  program,  61,  62 
Monetary  value,  41 
Moon  type,  191 

Moral  treatment  of  insanity,  18 
Mosso,  30 
Moving  pictures,  90 

N 

National  Committee  for  Mental 
Hygiene,  109 

Society  for  Promotion  of  Oc- 
cupational Therapy,  72 
Neff,  Dr.  Mary  Lawson,  42,  62 
Neuroses,  War,  106,  111,  113 
New  Jersey  State  Hospital  at 

Morris  Plains,  102 
New  York  Hospital,  20 

point,  191 

Normal  life,  definition  of,  46 
Nostiz,  24 
Nurses,  training  schools  for,  38, 

78 
Nutting,  Prof.  M.  Adelaide.  80 


O 


Occupation,  definition  of,  45 

director,  38,  50,  55 

for  feebleminded,  182 

for  women,  24,  42 

Henry  B.   Favill  School  of, 
119 

invalid,  43,  114 

rules  for  application  of,  56 

synonyms  for,  43 
Occupational  therapy,  117,  175 
and  social  service,  197 


Occupational  therapy,  and  the 
war,  106 

bibliography  of,  210 

definition  of,  43 

for  the  blind,  187 

principles  of,  227 
Orchestra,  92 
Outdoor  games,  93 


Paralyzed,  re-educational  exer- 
cises for,  28 

Parties,  95 

Pennsylvania  Hospital,  25 

Persecutory  ideas,  60 

Physical  education,  162 
therapy,  application  of,  177 

Pictures,  moving,  90 

Pinel,  18,  23 

Play  instinct,  64 

Point,  New  York,  191 

Posters,  95 

Presbyterian  Hospital  of  Chi- 
cago, 68 

Principles  of   occupational 
therapy,  227 

Program,  model,  61,  62 

Programs,  95 

Prosthetic  appliances,  126 

Psychiatric  clinic,  66,  67 

Psychology,  vocational,  37 

Q 

Qualifications  of  an  occupation 
director,  50 

R 

Ray,  Dr.  Isaac,  22 
Reading,  89 

Recalled  to  Life,  English  Jour- 
nal, 108 

Reconstruction  aide,  123 
Records,  58,  72 
Red  Cross,  119,  165,  201 

home  service,  201 

Institute,  123 


INDEX 


235 


Re-education,  vocational,  118 

Re-educational  exercises  for 
paralyzed,  28 

Reid,  Dr.  Eva  Charlotte,  18 

Reil,  Johann  Friederich,  20,  24, 
76 

Repair  work,  76 

Reunions,  24 

Revocational  education,  defini- 
tion of,  44 

Rewards,  205 

Ripley,  Dr.  Horace  G.,  62 

Robertson,  Sir  William,  164 

Roller,  24 

Roorbach,  Miss  Isabelle,  88 

Rossy,  186 

Rules  for  application  of  occu- 
pation, 56 

Rush,  Dr.  Benjamin,  20 


S 


Sale  of  articles,  74 

Salmon,  Dr.  Thomas  W.,  109 

Salpetriere,  24 

Sanderson,     Miss    Marguerite, 
123 

Schools,  24 

Schwzeigger,  24 

Sexton,  Dr.  F.  H.,  209 

Shell  shock,  106,  111,  113 

Sheppard  and  Enoch  Pratt  Hos- 
pital, 45,  81 

Shuttleworth  and  Potts,  184 

Simmons  College,  120 

Slagle,    Mrs.    Eleanor    Clarke, 
119,  198 

Social  service,  197 

Soldier's  heart,  178 

Sonnenstein,  24 

State  hospital,  59 

Stereotyped  acts,  60 

Stump,   amputated,   treatment 
of,  159 

Superintendent,  39,  44 
of  nurses,  40 


Surgeon-General,  120,  121,  126, 

159 
Sutton,  Dr.,  "armless"  billiard 

expert,  157 


Taunton  State  Hospital,  62 

Teachers  College,  123 

Tennis,  94 

Tests,  general,  34 
directions,  34 

Theatricals,  24 

Therapeutic  fashions,  17 

Tilting  table  for  hip  amputa- 
tions, 152 

Tournaments,  94 

Track  and  field  athletics,  95 

Tracy,  Miss  Susan  E.,  27,  68, 
83,  105,  120 

Training  schools  for  nurses,  38, 
78 

Treatment  of  amputated  stump, 
159 

Tuberculous,  29 

Type,  Moon,  191 
New  York,  191 

U 

Underwood,  Mr.  C.  N.,  140 
Upham,  Miss  Elizabeth  G.,  121 
Useless  work,  53 
Utica  State  Hospital,  98 


Vocational  education,  definition 

of,  44 
Federal  Board  of,  118,  121, 

123 

psychology,  37 
re-education,  118 
Rehabilitation,  Board  for,  123 
Volley  ball  games,  94 


236 


INDEX 


w 

War,  Civil,  27 

Great,  28,  51,  56,  106 
neuroses,  106,  111,  113 
Risk  Insurance  Bill,  120 

Washington  conference,  122 

Waste,  58,  74 

Water  cure,  17 

Whittling,  42 

Williamsburg  Asylum,  22 

Wisdom  of  leisure,  49 

Wood,  Derwent,  160 

Woodward  and  Wells,  35 


Work,  repair,  76 

useless,  53 
Workshops,  98 
Writing,  knee,  181 
Wyman,  Dr.,  21 


York  Retreat,  20 

Z 

Zander  apparatus,  165 


Books  for  Nurses 


PUBLISHED   BY 

W.    B.   SAUNDERS   COMPANY 

West  Washington  Square  Philadelphia 

London:    9,  Henrietta  Street,  Covent  Garden 

Sanders'  Nursing       NEW  &>  EDITION 

This  new  edition  is  undoubtedly  the  most  com- 
plete and  practical  work  on  nursing  ever  pub- 
lished. Miss  Sander's  already  superior  work 
has  been  amplified  and  the  methods  simplified  to 
bring  it  down  to  the  newest  ideas  in  nursing. 
There  is  none  other  so  full  of  good,  practical 
information  detailed  in  a  clean-cut,  definite  way. 

Modern  Methods  in  Nursing.  By  GEORGIANA  J.  SANDERS, 
formerly  Superintendent  of  Nurses  at  Massachusetts  Gen- 
eral Hospital.  12mo  of  900  pages,  with  217  illustrations. 
Cloth,  $2.50  net.  Published  August.  1916 

Dunton's  Occupation  Therapy 

EMPHASIZING   BASIC   PRINCIPLES 

Dr.  Dunton  gives  those  forms  likely  to  be  of  most 
service  to  the  nurse  in  private  practice.  You  get 
chapters  on  puzzles,  reading,  physical  exercises, 
card  games,  string,  paper,  wood,  plastic  and 
metal  work,  weaving,  picture  puzzles,  basketry, 
chair  caning,  bookbinding,  gardening,  nature 
study,  drawing,  painting,  pyrography,  needle- 
work, photography,  and  music. 


Our  books  are  revised  frequently,  so  that  the  edi- 
tion you  find  here  may  not  be  the  latest.  Write 
us  about  any  books  in  which  you  are  interested. 


Stoney's  Nursing 


(5,h)  EDITION 


Of  this  work  the  American  Journal  of  Nursing  says:  "It  is  the 
fullest  and  most  complete  and  may  well  be  recommended  as 
being  of  great  general  usefulness.  The  best  chapter  is  the  one 
on  observation  of  symptoms  which  is  very  thorough."  There 
are  directions  how  to  improvise  everything. 

Practical  Points  in  Nursing.  By  EMILY  M.  A.  STONEY.  Revised 
by  I/UCY  CORNELIA  CATLIN,  R.  N.,  Youngstown  Hospital,  Ohio. 
12mo.  511  pages,  illustrated.  Cloth,  $1.75  net.  Published  August,  1916 

Morse's  Bacteriology  for  Nurses  JUST  READY 

Dr.  Morse  presents  here  that  elementary  bacteriology  needed 
by  the  student  nurse  during  the  beginning  of  her  work.  The 
language  is  extremely  simple  and  untechnical,  so  that  the 
subject  can  be  easily  grasped.  Only  matter  germane  to  the 
subject  of  nursing  is  given. 

Bacteriology  for  Nurses.    By  M.  E.  MORSE,  M.D.,  Pathologist  to  the 
Boston  State  Hospital.    12mo  of  133  pages,  illustrated. 

Published  March.  1919 


NEW  (4th)  EDITION 


Stoney's  Surgical  Technic 

The  first  part  deals  with  bacteriology,  including  antitoxins;  the 
second  with  all  the  latest  developments  in  surgical  technic. 
The  National  Hospital  Record  says :  "Pregnant  with  just  the 
information  nurses  constantly  need." 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  M.  A. 
STONEY.  342  pages,  illustrated.  Cloth,  $1.75  net.  October,  1916 

Goodnow's  First-Year  Nursing    2d  EDITION 

Miss  Goodnow's  work  deals  entirely  with  the  practical  side  of 
first-year  nursing  work.  It  is  the  application  of  text-book 
knowledge.  It  tells  the'nurse  how  to  do  those  things  she  is  called 
upon  to  do  in  her  first  year  in  the  training  school — the  actual 
ward  work. 

First-Year  Nursing.  By  MINNIE  GOODNOW,  R.  N.,  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  12mo  of  354  pages, 
illustrated.  Cloth,  $1.50  net.  Published  February.  1W6 


Aikens'  Hospital  Management 

This  is  just  the  work  for  hospital  superintendents,  training- 
school  principals,  physicians,  and  all  who  are  actively  inter- 
ested in  hospital  administration.  The  Medical  Record  says: 
"Tells  in  concise  form  exactly  what  a  hospital  should  do 
and  how  it  should  be  run,  from  the  scrubwoman  up  to  its 
financing."  * 

Hospital  Management.  Arranged  and  edited  by  CHARLOTTE  A. 
AIKENS,  formerly  Director  of  Sibley  Memorial  Hospital,  Washing- 
ton, D.  C.  488  pages,  illustrated.  Cloth,  $3.00  net.  April,  1911 

Aikens'  Primary  Studies         NEW  (3d)  EDITION 

Trained  Nurse  and  Hospital  Review  says:  "  It  is  safe  to  say 
that  any  pupil  who  has  mastered  even  the  major  portion  of 
this  work  would  be  one  of  the  best  prepared  first  year  pupils 
who  ever  stood  for  examination." 

Primary  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  12mo  of 
472  pages,  illustrated.  Cloth,  $1.75  net.  Published  June,  1915 

Aikens'  Training-School  Methods  for 
Institutional  Nurses  NEW  (2d)  EDITION 

This  work  not  only  tells  how  to  teach,  b*it  also  what  should 
be  taught  the  nurse  and  how  m-u&k.  The  Medical  Record  says? 
"  This  book  is  original,  breezy  and  healthy." 

Hospital  Training-School  Methods  for  Institutional  Nurses.  By 
CHARLOTTE  A.  AIKENS,  formerly  Director  of  Sibley  Memorial 
Hospital,  Washington,  D.  C.  334  pages.  March,  1919 

Aikens'    Clinical    Studies       NEW  (3d)  EDITION 

This  work  for  second  and  third  year  students  is  written  oa  the 
same  lines  as  the  author's  successful  work  for  primary  stu- 
dents. Dietetic  and  Hygienic  Gazette  says  there  "  is  a  large 
amount  of  practical  information  in  this  book." 

Clinical  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKBNS,  farmery 
Birector  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  *»m«  »t 
56g  pages,  illustrated  Cloth,  $2.00  net.  Published  August,  KH6 


Bolduan  &  Grund's  Bacteriology  2d  EDITION 

The  authors  have  laid  particular  emphasis  on  the  immediate 
application  of  bacteriology  to  the  art  of  nursing.  It  is  an 
applied  bacteriology  in  the  truest  sense.  A  study  of  all  the 
ordinary  modes  of  transmission  of  infection  are  included. 

Applied  Bacteriology  for  Nurses.  By  CHARLES  F.  BOLDUAN,  M.D., 
Director  Bureau  of  Public  Health  Education,  and  MARIE  GRUND, 
M.  D  ,  Bacteriologist,  Department  of  Health,  City  of  New  York 
188  pages,  illustrated.  Cloth,  $1.50  net.  Published  November,  1916 

Harding's  Higher  Aspect  of  Nursing 

This  book  represents  the  deductions  from  the  author's  many 
years  of  personal  study  and  experience  both  in  the  training- 
school  and  in  the  field  of  practical  nursing  in  the  hospitals  and 
in  private. 

Higher  Aspect  of  Nursing.  12mo  of  300  pages.  By  GERTRUDE 
HARDING.  Published  February.  1919 


Beck's  Reference  Handbook 


THIRD  EDITION 


This  book  contains  all  the  information  that  a  nurse  requires 
to  carry  out  any  directions  given  by  the  physician.  The 
Montreal  Medical  Journal  says  it  is  "  cleverly  systematized  and 
•hows  close  observation  of  the  sickroom  and  hospital  regime." 

A  Reference  Handbook  for  Nurses.  By  AMANDA  K.  BECK,  Graduate 
of  the  Illinois  Training  School  for  Nurses,  Chicago,  111.  16mo  of  229 
pages.  Bound  in  flexible  leather,  $1.50  net.  February,  1913 


NEW  (2d) 
EDITION 


Roberts'  Bacteriology  &  Pathology 

This  new  work  is  practical  in  the  strictest  sense.  Written 
specially  for  nurses,  it  confines  itself  to  information  that  the 
nurse  should  know.  All  unessential  matter  is  excluded.  The 
style  is  concise  and  to  the  point,  yet  clear  and  plain.  The  text 
is  illustrated  throughout. 

Bacteriology  and  Pathology  for  Nurses.  By  JAY  G.  ROBERTS,  Ph.  G.. 
M.  D.,  Oskaloosa,  Iowa.     206  pages,  ijlus.     $1.50  net.          August.  19t6 


DeLee's  Obstetrics  for  Nurses 

Dr.  Del^ee's  book  really  considers  two  subjects  —  obstetrics 
for  nurses  and  actual  obstetric  nursing.  Trained  Nurse  and 
Hospital  Review  says  the  "book  abounds  with  practical 
suggestions,  and  they  are  given  with  such  clearness  that 
they  cannot  fail  to  leave  their  impress." 

Obstetrics  for  Nurses.  By  JOSEPH  B.  DE!,EE,  M.  D.,  Professor  of 
Obstetrics  at  the  Northwestern  University  Medical  School,  Chicago. 
12mo  volume  of  550  pages,  illustrated.  Cloth.  $2.75  net.  July.  1917 

Davis'  Obstetric  &  Gynecologic  Nursing 

JUST  OUT—  NEW  (5th)  EDITION 

The  Trained  Nurse  and  Hospital  Review  says:  "  This  is  one 
of  the  most  practical  and  useful  books  ever  presented  to  the 
nursing  profession."  The  text  is  illustrated. 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  M.  D., 
Professor  of  Obstetrics  in  the  Jefferson  Medical  College,  Philadel- 
phia. 498  pages,  illustrated.  Cloth,  $2.00  net.  Published  June.  1917 

Macfarlane's  Gynecology  for  Nurses 

THIRD  EDITION 

Dr.  A.  M.  Seabrook,  Woman's  Hospital  of  Philadelphia,  says: 
"It  is  a  most  admirable  little  book,  covering  in  a  concise  but 
attractive  way  the  subject  from  the  nurse's  standpoint." 

A  Reference  Handbook  of  Gynecology  for  Nurses.  By  CATHARINE 
MACFARLANE.  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia.  16mo  of  175  pages,  with  70  illustrations.  Flexible 
leather,  $1.50  net.  Published  October,  1918 


Asher's  Chemistry  and  Toxicology 

Dr.  Asher's  one  aim  was  to  emphasize  throughout  his  book 
!he  application  of  chemical  and  toxicologic  knowledge  in  the 
study  and  practice  of  nursing.  He  has  admirably  succeeded. 

12mo  of  209  pages.  By  PHILIP  ASHER,  PH.G.,  M.D.,  Dean  and  Pro- 
fessor of  Chemistry,  New  Orleans  College  of  Pharmacy.  Cloth, 
$1.50  net.  Published  October,  1918 


Aikens'  Home  Nurse's  Handbook 

The  point  about  this  work  is  this:  It  tells  you,  and  shows  you 
just  how  to  do  those  little  things  entirely  omitted  from  other 
nursing  books,  or  at  best  only  incidentally  treated.  The 
chapters  on  "Home  Treatments"  and  "Every-Day  Care  of 
the  Baby,"  stand  out  as  particularly  practical. 

Home  Nurse's  Handbook.  By  CHARLOTTE  A.  AIKENS.  formerly  Di- 
rector of  the  Sibley  Memorial  Hospital,  Washington,  D.  C.  izmo  of 
303  pages,  illustrated.  Cloth,  $1.50  net.  Published  March,  1917 

Eye,  Ear,  Nose,  and  Throat  Nursing 

This  book  is  written  from  beginning  to  end  for  the  nurse.  You 
get  antiseptics,  sterilization,  nurse's  duties,  etc.  You  get  an- 
atomy and  physiology,  common  remedies,  how  to  invert  the 
lids,  administer  drops,  solutions,  salves,  anesthetics,  the 
various  diseases  and  their  management.  New  (.2^)  Edition. 

Nursing  in  Diseases  of  the  Eye,  Ear,  Nose  and  Throat.  By  the 
Committee  on  Nurses  of  the  Manhattan  Eye,  Ear  and  Throat  Hospital. 
i2mo  of  291  pages,  illustrated.  Cloth,  $1.50  net.  Published  Sept.  1915 

Paul's  Materia  Medica  NEW  (*»  EDITION 

In  this  work  you  get  definitions — what  an  alkaloid  is,  an  In- 
fusion, a  mixture,  an  ointment,  a  solution,  a  tincture,  etc. 
Then  a  classification  of  drugs  according  to  their  physiologic 
action,  when  to  administer  drugs,  how  to  administer  them, 
and  how  much  to  give. 

A  Text-Book  of  Materia  Medica  for  Nurses.  By  GEORGE  P.  PAUL.  M.JJ. 
12mo  of  295  pages.  Cloth,  $1.50  net.  Published  August,  191  7 

Paul's  Fever  Nursing  NEW  (3d)  EDIT.ON 

In  the  first  part  you  get  chapters  on  fever  in  general,  hygiene, 
diet,  methods  for  reducing  the  fever,  complications.  In  the 
second  part  each  infection  is  taken  up  in  detail.  In  the  third 
part  you  get  antitoxins  and  vaccines,  bacteria,  warnings  of 
the  full  dose  of  drugs,  poison  antidotes,  enemata,  etc. 

Nursing  in  the  Acute  Infectious  Fevers.  By  GEORGE  P.  PAUL,  M.  D. 
12mo  ef  275  pages,  illustrated.  Cloth,  $1.00  net.  October.  1915 


McCombs'  Diseases  of  Children  for  Nurses 

NEW  (3d)    EDITION 

Dr.  McCombs'  experience  in  lecturing  to  nurses  has  enabled 
him  to  emphasize  just  those  points  that  ?iurses  ?nost  need  to  know. 
National  Hospital  Record  says:  "We  have  needed  a  good 
book  on  children's  diseases  and  this  volume  admirably  fills- 
the  want."  The  nurse's  side  has  been  written  by  head 
nurses,  very  valuable  being  the  work  of  Miss  Jennie  Manly. 

Diseases  of  Children  for  Nurses.  By  ROBERT  S.  McCoMBS,  M.  D.. 
Instructor  of  Nurses  at  the  Children's  Hospital  of  Philadelphia.  i2mo 
of  509  pages,  illustrated.  Cloth,  $2.25  net.  Published  June,  1916. 


(3d) 


Wilson's  Obstetric  Nursing  NEW 

In  Dr.  Wilson's  work  the  entire  subject  is  covered  from  the 
beginning  of  pregnancy,  its  course,  signs,  labor,  its  actual 
accomplishment,  the  puerperium  and  care  of  the  infant. 
American  Journal  of  Obstetrics  says:  "  Every  page  empasizes 
the  nurse's  relation  to  the  case." 

A  Reference  Handbook  of  Obstetric  Nursing.  By  W.  REYNOLDS. 
WILSON,  M.  D.,  Visiting  Physician  to  the  Philadelphia  Lying-in 
Charity.  258  pages,  illus.  Flexible  leather,  fl.50  net.  April.  1916- 


NEW  (10th)   EDITION 


American  Pocket  Dictionary 

The  Trained  Nurse  and  Hospital  Review  says:  "We  have 
had  many  occasions  to  refer  to  this  dictionary,  and  in  every 
instance  we  have  found  the  desired  information." 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  NE\\MAX 
DORLAND,  A.  M.,  M.  D.  Flexible  leather,  gold  edges,  $1.25  net; 
indexed,  $1.50  net.  Published  September.  1917 


THIRD- 
EDITION 


Lewis'  Anatomy  and  Physiology 

Nurses  Journal  of  Pacific  Coast  says  "it  is  not  in  any  sense 
rudimentary,  but  comprehensive  in  its  treatment  of  the  sub- 
jects." The  low  price  makes  this  book  particularly  attractive. 

Anatomy  and  Physiology  for  Nurses.     By  L.EROY  I/iwis.  M.D.     12mo- 
of  326  pages;    150  illustrations.     Cloth,  $1.75  net. 

Published  September.  1913- 


Goodnow's  War  Nursing 

Written  at  the  front  and  on  the  battlefield,  this  book  shows  the 
inexperienced  nurse  how  to  care  for  a  ward  of  wounded  men 
from  arrival  to  dismissal;  it  introduces  you  to  actual  conditions, 
and  shows  you  how  they  are  best  met. 

War  Nursing:  a  Text-Book  for  Auxiliary  Nurses.  By  MINNIE  GOOD- 
NOW.  R.  N.,  War  Nurse  in  France.  172  pages,  illustrated.  Cloth, 
$1.50  net.  Published  December,  1917 

Warnshuis'  Surgical  Nursing 

The  author  gives  you  here  the  essential  principles  of  surgical 
nursing,  and  reliable  fundamental  knowledge  based  on  his 
own  personal  conclusions  and  experiences.  Secondary  matter 
is  excluded,  and  all  primary  and  pertinent  points  are  set  down 
briefly  and  concisely. 

Octavo  of  2'7  pages,  with  255  illustrations.  By  FREDERICK  C. 
WARNSHUIS,  M.D.,  F.A.C.S.,  Visiting  Surgeon,  Butterworth  Hos- 
pital, Grand  Rapids,  Michigan.  Cloth,  $2.50  net. 

Published  March,  1918 

Friedenwald  and  Ruhrah's  Dietetics  for 

IN  UrseS  NEW  (4th)  EDITION 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse, 
both  in  training  school  and  after  graduation.  American  Jour- 
nal of  Nursing  says  it  "is  exactly  the  book  for  which  nurses 
and  others  have  long  and  vainly  sought." 

Dietetics  for  Nurses.  By  JULIUS  FRIEDENWALD,  M.  D.,  and  JOHN 
RUHRAH,  M.D.,  University  of  Maryland  School  of  Medicine  and 
College  of  Physicians  and  Surgeons,  Baltimore.  12mo  volume  of  467 
pages.  Cloth,  $1.50  net.  Published  July.  1917 


FIFTH 
EDITION 


Friedenwald  &  Ruhrah  on  Diet 

This  work  is  a  fuller  treatment  of  the  subject  of  diet,  pre- 
sented along  the  same  lines  as  the  smaller  work.     Everything 
concerning  diets,  their   preparation  and  use,  coloric  values, 
rectal  feeding,  etc.,  is  here  given  in  the  light  .of  the  most  re- 
cent researches.  Published  March,  1919 
Diet  in  Health  and  Disease.    By  JULIUS  FRIEDENWALD,  M.D.,  and 
JOHN  RUHRAH,  M.D.    Octavo  volume  of  919  pages. 


Catlin's  Hospital  Social  Service 

Miss  Catlin's  book  is  especially  planned  to  help  those  who  are 
establishing  social  service  centres  in  new  fields,  as  well  as 
those  in  dispensaries  already  firmly  established.  She  has  had 
the  practical  experience  of  many  years  to  draw  upon. 

NELIA  CATLIN,  R.  N.,  Director  of  Social  Service  Work,  Youngstown 
Hospital,  Ohio.  12mo  of  113  pages,  with  43  illustrations.  Cloth, 
$1.25  net.  Published  May,  1918 

Galbraith's  Personal  Hygiene  and  Physical 
Training  for  Women  NEW  <2d>  EDITION 

Dr.  Galbraith's  book  tells  you  how  to  train  the  physical  pow- 
ers to  their  highest  degree  of  efficiency  by  means  of  fresh  air, 
tonic  baths,  proper  food  and  clothing,  gymnastic  and  outdoor 
exercise.  There  are  chapters  on  the  skin,  hair,  development 
of  the  form,  carriage,  dancing,  walking,  running,  swimming, 
rowing,  and  other  outdoor  sports. 

Personal  Hygiene  and  Physical  Training  for  Women.  By  ANNA  M. 
GALBRAITH,  M.D.,  Fellow  New  York  Academy  of  Medicine,  izmo  of 
393  pages,  illustrated.  Cloth,  $2.25  net.  Published  January.  1917 

Galbraith's  Four  Epochs  of  Woman's  Life 

This  book  covers  each  epoch  fully,  in  a  clean,  instructive  way, 
taking  up  puberty,  menstruation,  marriage,  sexual  instinct, 
sterility,  pregnancy,  confinement,  nursing,  the  menopause. 

The  Four  Epochs  of  Women's  Life.  By  ANNA  M.  GALBRAITH,  M.D., 
with  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D.  12mo  of  296 
pages.  Cloth,  $1.50  net.  Third  Edition  published  March,  1917 

Griffith's  Care  of  the  Baby     NEw  <6th)  EDITION 

Here  is  a  book  that  tells  in  simple,  straightforward  language 
exactly  how  to  care  for  the  baby  in  health  and  disease ;  how 
to  keep  it  well  and  strong;  and  should  it  fall  sick,  how  to 
carry  out  the  physician's  instructions  and  nurse  it  back  to 
health  again.  Published  June.  1915 

The  Care  of  the  Baby.  By  J.  P.  CROZER  GRIFFITH,  M.D.,  Univers- 
ity of  Pennsylvania.  i2mo  of  458  pages,  illustrated.  Cloth,  $1.50  net 


Aikens'  Ethics  for  Nurses  PRINTING! 

This  book  emphasizes  the  importance  of  ethical  training.  It 
is  a  most  excellent  text-book,  particularly  well  adapted  for 
classroom  work.  The  illustrations  and  practical  problems 
used  in  the  book  are  drawn  from  life. 

Studies  in  Ethics  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Superintendent  of  Columbia  Hospital,  Pittsburg.  izmo  of  320  pages. 
Cloth,  $2.00  net.  Published  April.  1916 

Goodnow's  History  of  Nursing 

Miss  Goodnow's  work  gives  the  main  facts  of  nursing  history 
from  the  beginning  to  the  present  time.  It  is  suited  for  class- 
room work  or  postgraduate  reading.  Sufficient  details  and 
personalities  have  been  added  to  give  color  and  interest,  and 
to  present  a  picture  of  the  times  described. 

History  of  Nursing.  By  MINNIE  GOODNOW,  R.N.,  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  i2mo  of  370  pages, 
illustrated.  Cloth,  $2.00  net.  Published  December,  1916 

Berry's  Orthopedics  for  Nurses 

The  object  of  Dr.  Berry's  book  is  to  supply  the  nurse  with  a 
work  that  discusses  clearly  and  simply  the  diagnosis,  prog- 
nosis and  treatment  of  the  more  common  and  important  ortho- 
pedic deformities.  Many  illustrations  are  included.  The 
work  is  very  practical. 

Onhopedic  Surgery  for  Nurses.  By  JOHN  McWiLUAMS  BERRY. 
M.D.,  Clinicai  Professor  of  Orthopedics  and  Rontgenology,  Albany 
Medical  College.  Cloth,  $1.00  net.  Published  July,  1916 

Whiting's  Bandaging 

This  new  work  takes  up  each  bandage  in  detail,  telling  you — 
and  showing  you  by  original  illustrations — just  how  each 
bandage  should  be  applied,  each  turn  made.  Dr.  Whiting's 
teaching  experience  has  enabled  him  to  devise  means  for  over- 
coming common  errors  in  applying  bandages. 

Bandaging.  By  A.  D.  WHITING,  M.D.,  Ins4ructor  in  Surgery  at  the 
University  of  Pennsylvania,  izmo  of  151  pages,  with  117  Illustra- 
tions. Cloth,  $1.50  net.  Published  November,  1915 

10 


Smith's  Operating-Room 

The  object  is  to  show  you  how  to  assist  the  surgeon  according 
to  the  newest  operative  technic.  You  get  the  result  of  active 
experience  systematized,  and  in  concise  form.  You  get  a  thor- 
ough digest  of  every  essential ;  detailed  lists  of  instruments ; 
glossary  of  medical  terms.  Every  phase  of  the  subject  is 
covered  by  ample,  practical  instruction. 

The  Operating- Room.  A  Primer  for  Nurses.  By  AMY  ARMOUR 
SMITH,  R.N.,  formerly  Superintendent  of  Nurses  at  the  Woman's 
Hospital  of  the  State  of  New  York.  12mo  of  295  pages,  illustrated. 
Cloth.  $1.50  net.  Published  October.  1916 

Handler's  The  Expectant  Mother 

This  is  an  anatomy,  physiology  and  hygiene  covering  those 
points  and  functions  concerned  in  child-bearing  and  designed 
for  the  use  of  the  nurse  and  the  mother.  Every  question  of 
interest  to  the  expectant  mother  is  treated. 

The  Expectant  Mother.  By  S.  WYLLIS  BANDLER,  M.  D.,  Professor 
of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
and  Hospital.  Cloth,  $1.25  net.  Published  October,  1916 

Winslow's  Prevention  of  Disease 

Here  you  get  a  practical  guide,  giving  you  briefly  the  means 
to  avoid  the  various  diseases  described.  The  chapters  on  diet, 
exercise,  tea,  coffee,  alcohol,  prevention  of  cancer,  etc.,  are  of 
special  interest.  There  are,  besides,  chapters  on  the  preven- 
tion of  malaria,  colds,  constipation,  obesity,  nervous  disorders 
and  tuberculosis.  -It  is  a  record  of  twenty-five  years'  active 
practice. 

By  KENELM  WINSLOW,  M.D.,  formerly  Assistant  Professor  of  Com- 
perative  Therapeutics,  Harvard  University.  12mo  of  348  pages, 
illustrated.  Cloth.  $1.75  net.  'Published  November,  1916 

Brady's  Personal  Health 

This  is  different  from  other  health  books.  It  is  written  by  a 
physician  with  some  fifteen  years'  experience  in  writing  for  the 
laity.  It  covers  the  entire  range  of  health  questions — care  of 
mouth  and  teeth,  catching  cold,  adenoids  and  tonsils,  eye  and 
ear.  ventilation,  skin,  hair  and  nails,  nutrition,  nervous  ail- 
ments, etc. 

Personal  Health.      A   Doctor   Book  for  Discriminating  People.      By 

WILLIAM  BRADY,  M.D.,  Elmira,  N.Y.    12mo  of  400  pages. 

Cloth,  $1.50  net  Published  September.  1916 

11 


Hoxie's  Medicine  for  Nurses 


Medicine  for  Nurses  and  Housemothers.  By  GEORGE 
HOWARD  HOXIE,  M.D. ,  University  of  Kansas.  12mo 
of  390  pages,  illustrated.  Cloth,  $1.75  net. 

Third  Edition— February,  1918 

Bohm  &  Painter's  Massage 

Massage.   By  MAX  BOHM,  M.D.,  Berlin,  Germany.    Ed- 

.      ited  by  CITAS.  F.  PAINTER,  M.D. ,  Tufts  College.     Octavo 

of  91  pages,  97 illustrations.  Cloth,  $1.75  net.  June,  1913 

Boyd's  State  Registration  for  Nurses 

State  Registration  for  Nurses.  By  LOUIE  CROFT  BOYD, 
R.  N.,  Graduate  Colorado  Training  School  for  Nurses. 
Cloth,  $1.25  net.  Second  Edition— February,  1915 

Morrow's  Immediate  Care  of  Injured 

Immediate  Care  of  the  Injured.  By  ALBERT  S.  MOR- 
ROW, M.D. ,  New  York  Polyclinic.  Octavo  of  354  pages, 
with  242  illustrations.  Cloth,  $2.75  net. 

Third  Edition— November  y  1917 

deNancrede's  Anatomy  EIGHTH  EDITION 

Essentials  of  Anatomy.  By  CHARLES  B.  G.  DENAN- 
CREDE,  M.  D.,  University  of  Michigan.  12mo  of  400 
pages,  180  illustrations.  Cloth,  $1.50  net.  Oct.,  1911 

Montgomery's  Care  of  Surgical  Patients 

Care  of  Patients  Undergoing  Gynecologic  and  Abdom- 
inal Procedures  (BEFORE,  DURING,  AND  AFTER  OPERA- 
TION). By  E.  E.  MONTGOMERY,  A.M.,  M.D.,  LL.D., 
F.A.C.S.,  Professor  of  Gynecology  in  Jefferson  Medical 
College,  Philadelphia.  12mo  of  149  pages,  illustrated. 
Cloth,  $1.25  net.  Published  December,  1916 

Register's  Fever  Nursing 

A  Text-Book  on  Practical  Fever  Nursing.  By  EDWARD  C. 
REGISTER,  M.D. ,  North  Carolina  Medical  College.  Oc- 
tavo of  350  pages,  illustrated.  Cloth,  $2.50  net.  June  1907 


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